Categories
Binge Eating Disorder Dieting

Is Weight Suppression Driving Your Binge Eating?

Is Weight Suppression Driving Your Binge Eating?
Dall.e

If you have bulimia nervosa, did you know that being at a weight that is too low for your body could be a problem? And that it could be driving your binge eating and other behaviors?

Many people are aware that patients with anorexia nervosa need to gain weight in order to recover, but few people are aware that this may also apply to people with bulimia nervosa. This article will review research on the role of previous and current weight on the development and maintenance of bulimia nervosa.

What is Weight Suppression and Why Is It a Problem?

Weight suppression is the difference between one’s highest adult body weight and one’s current weight. It can also be thought of as the amount of weight one has lost from a previous high weight, most commonly in response to dieting.

Human bodies are meant to come in a variety of shapes and sizes. When a person of any size tries to reduce their size to smaller than that intended by their genetics, binge eating may be the body’s natural defense to avoid death by starvation and return the body to a healthier higher weight.

Weight loss decreases metabolism and the amount of energy the body burns. It also seems to increase appetite. The hormone leptin, which sends satiety signals to the brain, is believed to play a role in this process. Studies indicate that individuals with high weight suppression—that is, who have lost a lot of weight—appear to have lower levels of leptin. For these reasons, there is a strong biological predisposition to regain lost weight.

Early Research on Weight Suppression in Bulimia Nervosa

In 1979, Gerald Russell published the seminal paper that first described bulimia nervosa as a variant of anorexia nervosa. In this paper, he noted that weight suppression seemed to play a role in the development of bulimia nervosa. He described these patients as trying to drive their weight below a healthy body weight and, as a result, starting to binge and purge.

In Russell’s initial study of 30 patients with bulimia nervosa, 17 had previously met full criteria for anorexia nervosa, including the low weight. Another 7 patients had also lost weight, but not enough to qualify for anorexia nervosa. Every patient but one had experienced at least some weight loss prior to the onset of bulimia nervosa

Despite this early account, prior to the last 15 years there was not much research on weight suppression. More recently, several researchers have begun to study the impact of current and past weights on eating disorders. Although still in its early stage, this research is helping us to better understand the dangers of weight suppression.

Recent Research on Weight Suppression’s Role in Bulimia Nervosa

Research indicates that prior to the start of their illness, people with bulimia nervosa often start out at a higher than average body weight. As the eating disorder progresses, people with bulimia nervosa seem to lose a significant amount of weight. By the time they present for treatment, they are generally within what is usually considered a “healthy” weight range–-but crucially, they tend to be well below their highest adult weights. One study measuring the average degree of weight suppression in people with bulimia found the average amount of weight suppressed was approximately 30 pounds.

These findings indicate that individuals may use bulimic behaviors such as restricting and purging to avoid returning to higher body weights. Not surprisingly, greater weight suppression appears to be associated with more bulimic symptoms and a longer length of illness. Greater weight suppression also predicts weight gain in patients with bulimia nervosa both during and after treatment. The role of weight suppression is important because it illustrates that bulimia nervosa is not merely caused by psychological factors—complex biological factors are also at play.

Patients with weight suppression and bulimia nervosa who are preoccupied with achieving a lower weight appear to be stuck in a bio-behavioral bind. Their weight suppression makes them more prone to weight gain–-but the preoccupation with maintaining a lower weight makes this weight gain highly threatening.

Researchers do not yet fully understand whether as little as 5 pounds of weight suppression is problematic, or whether only larger amounts of weight suppression are an issue. They also do not know whether the effects of weight suppression are greater if someone was at a higher weight for a longer period of time or whether their weight has been suppressed for a longer time. These are among the answers that researchers studying weight suppression hope to be able to answer.

What Does this Mean for People With Bulimia Nervosa?

Juarascio and colleagues (2017) suggest that some patients who do not recover with a course of Cognitive Behavioral Therapy (CBT) for bulimia nervosa might improve their recovery by gaining weight. It appears that weight gain could reduce the urge to binge and purge. They recommend that clinicians routinely and thoroughly assess for relevant weight history. They also recommend that patients with significant weight suppression and those who gain weight during the initiation of regular eating should receive additional education about the impact of weight suppression on symptoms of bulimia nervosa. They also recommend that clinicians educate patients about the fact that over time, dieting often backfires and leads to weight gain.

Thus, even if you are eating enough and not restricting intake, continuing to binge may indicate that you need to gain weight. Successful treatment may include accepting that genetics contribute to variations in body size and shape and that your appropriate weight may be one that is higher than you now prefer. You are not destined to inhabit the same body as someone else.

Self-acceptance can be hard psychological work, but this is one place where we can help support you. Keep in mind that the alternative to acceptance may be a continuation of bingeing and purging.

How Do I Know if My Weight is Suppressed?

Some questions to consider:

  • Is your current weight lower than your highest adult weight?
  • Are you preoccupied with thoughts about food?
  • Do you experience episodes of eating in which you eat unusually large amounts of food in a short period of time and feel out of control while doing so?
  • Do you eat impulsively–when you haven’t planned to–or engage in emotional eating?

If more than one of the above is true, consider seeking help and gaining some weight. Getting to a weight that is biologically determined healthy for you, regardless of where that number is on population norms, is usually the healthiest. We do not yet have enough research to know whether you would need to go back to your highest weight, or whether regaining some of the suppressed weight may be sufficient. You may find that weight gain will relieve some preoccupation with food, reduce some symptoms of bulimia nervosa, and generally improve the quality of your life. You may also discover that the negative consequences of weight gain that you fear do not come true.

When weight is not suppressed you can more fully enjoy eating a variety of foods without obsessive worry and live life more fully. You can go out for dinner and enjoy a drink, indulge in a cupcake for a coworker’s birthday, and travel to a different region and experience the local cuisine all without accompanying anxiety.

This is a good blog post where one woman discussed accepting a higher body weight and living more fully.

Sources

L Butryn, Meghan, Michael Lowe, Debra Safer, and W Stewart Agras. 2006. Weight Suppression Is a Robust Predictor of Outcome in the Cognitive-Behavioral Treatment of Bulimia Nervosa. Vol. 115. https://doi.org/10.1037/0021-843X.115.1.62.

Gorrell S, Reilly EE, Schaumberg K, Anderson LM, Donahue JM. Weight suppression and its relation to eating disorder and weight outcomes: a narrative review. Eat Disord. 2019 Jan-Feb;27(1):52-81. doi: 10.1080/10640266.2018.1499297. Epub 2018 Jul 24. PMID: 30040543; PMCID: PMC6377342.

Juarascio, Adrienne, Elin L. Lantz, Alexandra Muratore, and Michael Lowe. 2017. “Addressing Weight Suppression to Improve Treatment Outcome for Bulimia Nervosa.” Cognitive and Behavioral Practice, October. https://doi.org/10.1016/j.cbpra.2017.09.004.

Keel, Pamela K., Lindsay P. Bodell, Alissa A. Haedt-Matt, Diana L. Williams, and Jonathan Appelbaum. 2017. “Weight Suppression and Bulimic Syndrome Maintenance: Preliminary Findings for the Mediating Role of Leptin.” The International Journal of Eating Disorders 50 (12):1432–36. https://doi.org/10.1002/eat.22788.

Keel, Pamela K., and Todd F. Heatherton. 2010. “Weight Suppression Predicts Maintenance and Onset of Bulimic Syndromes at 10-Year Follow-Up.” Journal of Abnormal Psychology 119 (2):268–75. https://doi.org/10.1037/a0019190.

Keel, Pamela K., Lindsay P. Bodell, Alissa A. Haedt-Matt, Diana L. Williams, and Jonathan Appelbaum. 2017. “Weight Suppression and Bulimic Syndrome Maintenance: Preliminary Findings for the Mediating Role of Leptin.” The International Journal of Eating Disorders 50 (12):1432–36. https://doi.org/10.1002/eat.22788.

Keel PK, Bodell LP, Forney KJ, Appelbaum J, Williams D. Examining weight suppression as a transdiagnostic factor influencing illness trajectory in bulimic eating disorders. Physiol Behav. 2019 Sep 1;208:112565. doi: 10.1016/j.physbeh.2019.112565. Epub 2019 May 30. PMID: 31153878; PMCID: PMC6636832.

Russell, G. 1979. “Bulimia Nervosa: An Ominous Variant of Anorexia Nervosa.” Psychological Medicine 9 (3):429–48.

Categories
ARFID

Adults with ARFID

Dall.e

Avoidant Restrictive Food Intake Disorder (ARFID) was only recognized as a disorder affecting those older than age 6 as recently as 2013. Treatment and recognition of this disorder are in their infancy. Thus, many people with ARFID have lived with it for years without any treatment. Many adults with ARFID have simply had to learn to cope with it on their own.

I have been facilitating a free support group for adults with ARFID in California for the past two years.  During this time over 80 people have come through the group. This has given me a window into what life is like for adults with ARFID.

What is ARFID?

ARFID is an eating disorder in which difficulty in eating enough food negatively impacts either the patient’s health or their ability to manage school or career and social life. Unlike anorexia nervosa, bulimia nervosa, or binge eating disorder, insufficient eating in ARFID is not primarily driven by the desire to modify one’s shape and size.

It is important to recognize that ARFID is a heterogeneous disorder. There are three main types.

  • Sensory sensitivity. People who have sensory sensitivity have often been picky eaters since childhood. They may be very sensitive to differences in taste and texture and cling to a narrow range of foods, most often struggling the most with vegetables, fruit, and meats—the foods most likely to have been poisonous to our ancestors.
  • Low interest. Also often developing in early childhood, people with low interest tend to have less interest in eating, experience less hunger and find food less rewarding. It is theorized that these people may be born with relatively low hunger hormone levels
  • Aversive consequences. This type tends to develop later in life in those who have a predisposition to be anxious. In response to a triggering event—such as having the stomach flu or watching someone choke—people may fear potential negative events such as vomiting, choking, or gastrointestinal distress that can occur after eating. As a result, they may start to phobically avoid eating certain foods or eating altogether.

People with ARFID often have more than one type, and they may also have another eating disorder such as anorexia or bulimia, or a history of one.

There is one promising treatment for adults with ARFID and that is CBT-AR. While this can help many, my group illustrates that this treatment is hard to access and may not adequately address all the impacts of living with this disorder for many years. In fact, the creators of CBT-AR acknowledge that successful treatment will not likely make a person “a foodie” and there may be residual features.

Impact of Living with ARFID

While there is a multitude of differences among the people with ARFID, here are some common themes.

Being misunderstood. Many adults with ARFID report a long history of not knowing what was wrong with them, families not understanding how to feed them, and even professionals providing misdiagnoses (e.g., anorexia). Those who did receive treatment almost always report that they were treated as if they had anorexia—treatment providers refused to believe they did not have body image concerns that were driving their restriction. Most reported not fitting into traditional eating disorder spaces and many report never having met another person with ARFID.

Shame. Many adults with ARFID report shame about their limited diet or about their preferred foods. They feel embarrassed when they order off the kids’ menu or modify meals at restaurants or are unable to eat with peers. Some have been teased about their narrow palate. They report feeling very self-conscious when others ask about their eating struggles.

Overwhelmed by having to provide meals for themselves. When I assess people with ARFID, one of the questions most universally endorsed (from the PARDI, an assessment measure) is “I find eating to be a chore.” People with ARFID don’t typically look forward to eating; even so, they have to ensure they eat, usually 5 to 6 times a day to maintain a minimum healthy weight for their bodies. When eating is a chore, unrewarding, perhaps even terrifying, this can be a heavy burden.

Many have trouble preparing their own meals.  These people can benefit from support and structure. A participant who did fine as long as meals were provided by their workplace, started to struggle only during the pandemic when they started to work from home.  Many adults with ARFID have trouble identifying any foods that appeal to them and find choosing foods overwhelming.

Social consequences. The problems with eating have reverberations much beyond eating. It often significantly impacts social interactions because so many social interactions involve meals.  Many adults report their ARFID limits their ability to socialize. They may dread eating with others or socializing at all, feel left out when others are sharing food, and be so repelled by the food eaten by others that it is hard to even sit with them. One group member reported that whenever someone tried to comment on their food choice they would deflect to change the conversation. Others feel guilt for placing limits on where their friends can eat with them.

Sensory overwhelm. Many have sensory “superpowers” which can be more of a curse than a blessing. Many in the group report such a sensitivity to smells that they cannot be around others eating certain smelly foods, a disinterest in eating if something has been prepared in the kitchen or microwave before them. Several adults report problems with doing the dishes after meals because of disgust around the smells and residue on the dishes. People with ARFID report having to use various strategies to manage dirty dishes.

Difficulty with flexibility. Similarly, many adults with ARFID report strong allegiance to particular brands or restaurants and have great difficulty if any aspect of a preferred food is varied. Many can report that others have often tried to pass off a different product as “the same” and they can always detect a difference. This makes eating in different locations and especially travel, particularly hard.

Anxiety. Anxiety is a common experience for adults living with ARFID, especially in those with a fear of aversive consequences presentation. Research indicates that people with ARFID often have other anxiety disorders, including OCD. Many individuals with ARFID experience anxiety in areas besides eating.

Gastrointestinal distress. Overlap with disorders of gut-brain interaction (DGBI) are common. Many with a history of gastrointestinal (GI) symptoms may restrict eating in order to avoid further symptoms. An individual with ARFID may be more sensitive to sensations in their body and digestive tract.  They may also have a predisposition to anxiety which can contribute to GI symptoms. Nausea is a common sensation and several group members report assistance from medications that help with nausea.

Neurodiversity. Many group attendees self-identify as neurodivergent. Although research is limited, many researchers and providers have noted the overlap between ARFID and autism or attention deficit hyperactivity disorder (ADHD). Individuals with autism often have greater sensory sensitivity and rigidity, features that overlap with symptoms of ARFID. People with ARFID and neurodivergence may also struggle with issues of attention, information processing, and social interactions.

 

We need more resources for adults with ARFID as demonstrated by the participants in my group and their desire to learn more about their condition and to educate others. We are collaborating with other professionals to share and develop more resources for people with ARFID.

ARFID Groups

We have a FREE weekly Adult ARFID support group for adults in California with ARFID.

We also have a monthly support group for parents of people 10 to 20 with ARFID, open to people in any location.

Categories
Eating Disorders Los Angeles

Low-Cost Eating Disorder Psychotherapy Now Available

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.

Categories
Eating Disorders Evidence-based treatment

Structuring Your Eating Disorder Recovery Environment

 

Recovery is challenging! I am repeatedly moved and impressed by the courage of my patients as they work through recovery from an eating disorder. One strategy that can help support recovery is a careful ​structuring of one’s recovery environment. This applies to adults working individually in treatment as well as to families helping adolescents to recover.

Most evidence-based treatments including cognitive-behavioral therapy (CBT) suggest that patients consider the timing of the start of treatment and potentially postpone it if they anticipate major distractions that will impede recovery. Similarly, it can be helpful when possible to try to minimize challenges.

Recovery looks different for everyone. Some patients are ambivalent about treatment and the changes it will require. Others are eager to be recovered from their eating disorder and just want to get on with life. And many may feel the urge to rush recovery. But I encourage you to “take it slow.”

Recovery 101

As a behaviorist, I like to think of recovery as a set of skills that are learned, developed, and practiced in increasingly challenging environments. Whether you are transitioning to an outpatient level of care or beginning treatment as an outpatient or supporting a teen in recovery at home, those first few months should be treated like “Recovery 101.” This is a training phase in which you are first learning and trying out recovery skills. Your abilities will become more fine-tuned as you practice increasingly difficult skills.

In this phase, it is best to be in a highly structured environment without too many complexities. Most people do best with structure. This is why settings housing large numbers of people tend to be highly structured. (I know – I worked in LA County Jail for 10 years.) This is also why higher levels of care with the sickest patients are highly structured. Structure makes things predictable and reduces anxiety.

In a structured setting, it is easier to follow a routine, such as eating at a regular time, having a familiar meal, and facing fewer distractions. Chaotic and unstructured environments are unpredictable, are more challenging for recovery, and require more advanced and flexible recovery skills.

The Challenge of Environment

In Recovery 101, it is often easiest to start by keeping things simple and predictable. Each element that adds complexity or uncertainty to the environment presents an additional challenge to someone with an eating disorder. Novel situations, different foods, different food venues, and different companions can all bring anxiety to those in early recovery. Any deviation from a routine requires additional skills, so handling each of these should be viewed as a new skill to master.

We can think about this as a ladder with each rung adding new difficulty. At the bottom is generally eating meals at home with support from immediate family. The next rungs might include:

  • Having friends or relatives over for dinner
  • Eating at a close friend’s house
  • Eating at a restaurant where individual entrees are served
  • Eating at a family-style restaurant
  • Eating at a buffet.

Each higher rung on the ladder requires more decisions and thus more skill. Each skill must be practiced.

Take it Slow

Many patients are tempted to climb the ladder quickly, rushing towards the more complicated and challenging situations. This is not advisable when someone is in Recovery 101. Some challenges are better left until recovery skills are stronger, if at all possible. It is easiest to learn skills first in one place and then to practice them in different settings. It is in this way that skills will generalize.

More advanced challenges that may best wait until the basic skills are mastered will vary from individual to individual, but these can include situations such as:

  • Weekend schedules when you have slept late (do you count brunch as breakfast or lunch and how do you handle the rest of the meals when your first meal is 3 hours late?)
  • Cooking for oneself
  • Going to unfamiliar restaurants
  • Eating at a small-plates, buffet, or family-style restaurant
  • Foreign travel to countries where the foods may be entirely unfamiliar

Instead of taking on advanced challenges all at once, consider potential ways to structure the environment during early eating disorder recovery:

  • Having meals planned out for the entire week
  • Eating meals at regular times
  • Regular grocery shopping
  • Having a backup plan (in case you run late or a plan changes)
  • Always carrying snacks (and backup snacks)
  • Planning alternative activities for high-risk times (for many patients that is evenings spent at home. For one patient, that meant going out on evenings her husband would not be home for dinner.)
  • Limiting meals at unfamiliar restaurants
  • Only bringing into the home small quantities of foods on which you have binged
  • Having a support person you can call
  • Structured schedules for every day of the week, including weekends
  • Careful planning ahead (with your team if you have one) for any situation you have not yet practiced

Keep in mind that you may experience setbacks. Sometimes you have to go back down the ladder before going back up again. This is a normal part of recovery.

When recovery is further along, you will be better able to handle more complex and challenging situations. Flexibility will come, but for now, keep it simple.

 

Categories
Eating Disorders Family based treatment

Adjunctive Therapies to FBT: What are the Additional Therapies That May be Added to FBT? And When Should They Be Added?

Photo by Lesly Juarez on Unsplash

In a previous post, I have discussed who is typically on an FBT team. In its traditional manualized form, the core team is a therapist, a medical doctor, and the parents. The team can also include a registered dietitian nutritionist (to guide the parents) and may include a psychiatrist.

It is not uncommon for medical providers unfamiliar with FBT and treatment centers to encourage additional individual therapy for the patient. As I have said previously, this is not always advisable. In FBT, less can be more—the work of the parents may be undermined by an individual therapist who either does not believe in or does not support FBT.

So, I thought it would be useful to describe in greater detail the situations in which I think additional therapies are warranted and which therapies are most aligned with FBT.

FBT is primarily a behavioral treatment, administered by parents. The two therapies I discuss below—Dialectical Behavior Therapy and Exposure and Response Prevention—are also behavioral treatments that can be applied consistently alongside FBT without confusion. By contrast, non-behaviorally-based therapies may create splitting or confusion when offered alongside FBT. In particular, you should be cautious about and avoid therapies that do not reinforce the parents’ authority over eating or introduce different theories about the cause of an eating disorder.

Comprehensive Dialectical Behavioral Therapy

Dialectical Behavioral Therapy (DBT) is a form of cognitive-behavioral treatment (CBT) developed in the 1980s by Marsha Linehan, Ph.D. It was developed to treat chronically suicidal individuals diagnosed with borderline personality disorder and is now considered the most effective treatment for this population. Research has demonstrated its effectiveness for a range of other mental disorders including substance dependence, depression, post-traumatic stress disorder (PTSD), and eating disorders.

DBT stands out as the treatment of choice for people with difficulty regulating emotions—those prone to outbursts of anger and impulsive behaviors such as self-harm and purging. It focuses on the teaching of skills to tolerate emotions and improve relationships.

Be aware that there are many therapists (including us!) who use DBT skills in individual therapy with clients. Some therapists also may offer a standalone DBT skills training group. However, while these individual elements of DBT treatment may be beneficial, comprehensive DBT has a powerful advantage.

For DBT to by comprehensive it must comprise the following components:

  • DBT skills training. This almost always occurs in a group format run like a class. Group leaders teach behavioral skills and assign homework. Groups meet weekly for 24 weeks to complete the curriculum. Skills training consists of four modules: Mindfulness, Distress Tolerance, Interpersonal Effectiveness, and Emotion Regulation.
  • Individual therapy. Weekly sessions run concurrently with the skills training. The individual therapist helps clients apply the DBT skills.
  • Phone coaching. Clients are encouraged to reach out to their individual therapists to receive in-the-moment support applying skills during times of need.
  • DBT Consultation Team to Support the Therapist. All the members of the DBT team (group therapists and individual therapists) support each other in managing these clients who are in high distress.

When a teen is in comprehensive DBT, there is usually a parallel track for the parents that includes a parent skills group and a parent phone coach so that the parents receive help supporting their teen who is learning to apply DBT skills.

Exposure and Response Prevention

Exposure and Response Prevention (ERP) refers to specific CBT strategies used to address obsessive-compulsive disorder (OCD) or similar symptoms. OCD is characterized by distressing and intrusive thoughts and compulsive behaviors in which a person engages to try to reduce the distress. In ERP, the patient is exposed to the distressing situation and encouraged to prevent their compulsive behavior so they can learn to tolerate the distress. Once a person feels capable of handling their distress they will no longer need to engage in the compulsive behavior.

OCD and eating disorders commonly co-occur, and eating disorders can result in compulsive behaviors that require additional attention, such as compulsive exercise or other rituals not related to eating. Patients with eating disorders who engage in these behaviors may benefit from the addition of ERP.

Categories
Eating Disorders Psychotherapy

Do I Need to Quit X to Stay in Recovery?

Dall.e

By Carolyn Hersh, LCSW, Staff Therapist

A difficult concept in recovery is knowing when to let go of an activity or even a job that could potentially re-ignite the eating disorder. As a therapist I find myself guiding my clients towards the realization that the sport or career path they had loved so much might be the very thing that holds them back and sets them back up for relapse. It isn’t always an easy decision.

Letting go of something that may have predated the eating disorder can lead to questions as to why it cannot remain in someone’s life in recovery. Many clients in the early stages of eating disorder treatment have to face the fact that they have to stop their sports if they are trying to regain weight or are working on eliminating behaviors that could leave the body physically weak. It is no surprise that once stabilization begins there is an urge to return to previously enjoyed activities. However, returning to these activities could potentially hinder full recovery.

Sports like gymnastics, running, figure skating, wrestling, and dancing are incredibly wonderful. As a figure skater myself, I can attest there is no greater feeling than gliding over the ice. But these same sports, especially at the elite level, can be incredibly demanding on the body. Behaviors required for full recovery can go against what a coach may be preaching to athletes to be in top physical form. What is expected of top athletes could look like disordered eating and poor body mentality from an outside perspective. The eating disorder itself may take what is used to condition a top athlete and manipulate it for its own gain.

It can be difficult to find the balance between a recovered mindset and meeting the demands of a sport or career. With some of my clients in the entertainment industry, there are pressures to look a certain way and fit a mold that their bodies may not be meant to fit. It can be difficult to navigate knowing they need to eat a certain amount of times a day and then have an agent say, “Lose five pounds for this role.”

The hardest decision is when there is a realization that staying in either the sport or career is just too detrimental to your health. It is certainly not easy to walk away from something you’ve put work into. And that can also be said about your recovery. Are you willing to give up a healthy body and mind for a potential chance at a gold medal or lucrative career even if it means killing yourself along the way? I’ve worked with a client who was a dancer who recognized as she was going through treatment that going back into a dance studio would be too triggering. She knew that staring at herself in a mirror and comparing herself to her classmates would lead to restricting her meals. It wasn’t an easy decision to walk away, but she knew there was no way she was in a place to be able to dance without being triggered.

In some circumstances, you may not have to completely quit your previous passion.  You might be able to approach the activity differently. You may not be able to return to a sport as an elite athlete, but you could still engage in the activity at a more recreational level. I’ve seen some of my clients shift from being an athlete to being a coach. Actors going from television and movies to doing local theater.  Sometimes you can still do what you love but it just needs to be re-configured to fit into your recovery lifestyle. For many, it can be comforting to know they can still act or model or run, but just do it less intensively.

You may also have the option of challenging what a sport or career emphasizes as far as body image and diet pressures. There are many models and actors who are embracing bigger bodies and not letting the pressures to lose weight define them. With this option, there is a risk of rejection along the way as we do still live in a culture that overvalues thinness. With that being said, this may be a safe option primarily for those who feel stable in recovery and are able to actively use coping skills to fight urges. If your recovery has reached a place of advocacy this definitely could be a path to take.

Leaving a passion behind or re-defining how it fits into your life can be a huge change. You may feel sad or mad. That’s okay. Ultimately, the decision you make will be the one that supports you in your recovery. If staying in the activity is going to trigger calorie counting, weekly weigh-ins or criticism for not looking a certain way, is it worth it? If you know where the eating disorder thrives then why play with fire? Ultimately, the decision will be based on what will make you healthy and happy and not allow you to compromise with the eating disorder.

Categories
Eating Disorders

Seven Reasons You Should Eat When You’re Not Hungry

Representation Matters
One of the cardinal rules of dieting is “Eat only when you’re hungry.” I often find that the fear of eating when not hungry is one of the most difficult bits of dogma to overcome. People with eating disorders and good dieters everywhere have been taught that this is all that stands in the way between us and complete loss of control and utter disaster in our lives. Many don’t even see it as an actual choice or symptom of the eating disorder.

Successful recovery from an eating disorder or disordered eating or chronic dieting requires overcoming and challenging this rule.

Just off the top of my head, I can think of a lot of reasons to eat when not hungry. Here are a few related to disordered eating:

  1. You have overridden your hunger cues for years from cycles of dieting, bingeing and purging. You don’t recognize normal hunger cues or satiety. Your treatment team has told you to eat regularly—three meals and two to three snacks per day. You feel like it is too much food and you’re not hungry. Should you follow their meal plan? Yes! Eating regularly is a crucial step in recovering from any eating disorder and it helps to regulate your hormones and circadian rhythms so you can regain your hunger and satiety cues and become a more intuitive eater.

 

  1. You are in recovery from a restrictive eating disorder and rarely feel hunger. You are told you need to eat more, but you don’t believe it. Isn’t it better to delay eating until later in the day? Should you really eat breakfast and lunch at the times scheduled by your dietitian? Yes, absolutely! Regular meals are critical to getting all of your body functions to work properly again. One of the reasons you may not be feeling adequate hunger could be delayed gastric emptying, which occurs when someone is undereating and food remains in the stomach far longer than it should. One of the consequences is low appetite. The solution: eat regularly as prescribed, even if you’re not hungry.

 

I can think of many more situations that apply to all of us, not just those with eating disorders:

  1. You normally eat dinner at 7 pm and your circadian rhythm is conditioned to get hungry then. But your sister has scheduled a family dinner at 5:30 to accommodate her children so they won’t be cranky at the table. Should you eat at 5:30 before you are hungry? Absolutely! Adjusting our schedules allows us to have meaningful social interactions that typically revolve around eating.

 

  1. You have a meeting that is scheduled from 12 to 3 pm. You’re not hungry at 11 am; breakfast was only at 8:30. You have the option to have a proper lunch at 11:30. Should you? Of course! Be practical—it’s better to eat before your meeting. Then you’ll be properly fueled and will be better able to concentrate during the meeting. Our brains don’t function as well when they’re low on glucose. Planning ahead and adjusting mealtimes accordingly is an important act of self-care.

 

  1. You are traveling to another country. You arrive at your destination and it’s dinnertime. Your circadian rhythms are all thrown off. You feel like you’ve been eating constantly. Should you eat? Yes! Acclimation to a new time zone is ushered along by institution of regular eating at the times appropriate to the destination. You will adjust faster if you get your body in synch.

 

  1. You just had a rough breakup. You’re eating meals, but sad. Your friends show up and want to take you out for ice cream to cheer you up. You’re not hungry. Should you go and eat ice cream with your friends? Absolutely! Food is not solely about nutrition – it’s also about bonding and comfort, and you should let the ice cream and your friends soothe your broken heart.

 

  1. You’re stressed and preparing for a presentation tomorrow. You’ve eaten adequately throughout the day and are not truly hungry. But you know that crunching on some popcorn will soothe your nerves. This is an old behavior that you’ve overused in the past. Contrary to popular belief, emotional eating is not itself a problem. Food is our earliest comfort and humans are designed to find food to be rewarding. If it were not, we would have died out as a species. There is no shame in using food as comfort—what can be problematic is if there are no other tools in your emotional toolkit. If eating is your only coping skill then I encourage you to learn some other strategies for managing negative emotions to give you a broader range of alternatives.

 

So, not eating when you’re not hungry is a rule that should be confronted. How can you start to challenge this rule and, if you have one, the eating disorder that uses it as an excuse?

You must face it head-on with new behaviors, deliberately defying it. If you have been instructed to follow a meal plan: follow it. If you have been told you are undereating: practice eating one thing per day when you are not hungry. The next time you have something in your schedule that interferes with a normal meal time: eat beforehand. Accept invitations to eat at times to which you are unaccustomed. Eat something spontaneously when it shows up, even if you are not hungry.

By practicing these behaviors, you will become less fearful of eating when not hungry. You will learn that this, too, is a normal part of being a human. You will be more relaxed around food and you will see that nothing horrible happens if you eat when you’re not hungry. You do not have to continue to be a victim of diet culture.

Categories
Family based treatment

Participating on an FBT Team

Image by griffert from Pixabay
Family-based treatment (FBT) is the leading evidence-based treatment for teens with anorexia nervosa and bulimia nervosa. While in an ideal world, every person with an eating disorder would have access to a full treatment team including a therapist, a dietitian, a medical doctor, and a psychiatrist, FBT calls only for a therapist to guide the parents and a medical doctor to manage medical needs. A dietitian is not required, but I have found that a dietitian who works primarily with the parents can provide valuable guidance. Sometimes there are other treatment providers. If there are multiple providers, it is important that team members are in agreement about treatment philosophy and goals. Otherwise, a nonaligned team can potentially be detrimental.

Overview of FBT (3 phases)

Family-based treatment is a manualized therapy, presented in a “manual” with a series of prescribed goals and techniques to be used during each phase of treatment. It focuses on empowering the parents to play a central role in their child’s recovery, using contingencies to reverse malnutrition, increase weight, and eliminate symptoms including restrictive eating, bingeing, purging, and overexercise. FBT is based on five principles:

  • Agnostic view of illness—there is no need to find a cause or underlying issue that caused the illness.
  • Initial symptom focus—the focus is on reversing malnutrition and eliminating other eating disorder behaviors.
  • Family responsible for refeeding/addressing behaviors—parents are empowered to take charge of all meals—including planning, cooking, serving, and supervision—to ensure they are consumed as well as preventing other behaviors such as bingeing and purging.
  • Non-authoritarian stance—the therapist is a guide and partner that empowers parents to help their child.
  • Externalization of illness—the illness is seen as an external force that is threatening the child’s life.

FBT consists of three phases:

  • Phase 1: Parents are fully in charge of and supervise all meals until behaviors have largely ceased and weight is nearly restored.
  • Phase 2: Once behaviors are largely eliminated, weight is nearly fully restored, and meals are going smoothly, parents gradually hand back some control of eating to the adolescent in an age-appropriate manner.
  • Phase 3: Once the adolescent has resumed age-appropriate independence over their own eating, the focus of therapy turns to other adolescent development issues, any remaining comorbid problems, and relapse prevention.

When to Add Other Providers

Many parents are incredulous that family-based treatment is a standalone treatment. It is primarily a behavioral treatment focused initially on a brain rescue and then on eliminating symptoms. Medical providers unfamiliar with FBT and treatment centers that insist on having complete teams may pressure families to add an individual therapist for the patient with the eating disorder to the team. This is not always advisable. Sometimes, in FBT, less is more; the work of the parents can be undermined by an individual therapist who either does not believe in or support FBT. Additionally, research shows that at least in the case of bulimia nervosa, no additional therapy may be needed: issues with depression and self-esteem resolved during FBT treatment.

In one case series of families with “failed FBT” several families pivoted to individual therapy and the teens later admitted that “they had asked for individual treatment as a deliberate strategy to exclude their parents because they knew it would mean that there would be less pressure for weight gain and more chances of avoiding stress and conflicts around the challenges related to their eating behavior.” This should serve as a caution against adding an individual therapist reflexively just because the teen is asking for it.

Dietitians

For families that want to work with a dietician who is familiar with FBT, my colleague, Katie Grubiak, RDN, and I have worked out the following successful protocol. In Phase 1 of FBT, the dietitian is only included when needed and only meets with the parents. This helps to empower the parents and prevents the dietitian from inadvertently colluding with the eating disorder. When a dietitian meets the teen too soon, we have found that the eating disorder tries to ally with the dietitian and the teen spends the time trying to negotiate for preferred “eating disorder foods.” We find it more effective to avoid giving the eating disorder that voice. Parents—who have after all been feeding their child since birth—know what their teen truly likes and can avoid being manipulated by the eating disorder.

The situations in which I have found the dietitian to be necessary include the following:

  • The adolescent has another issue that necessitates dietary restriction such as celiac disease, diabetes, or a food allergy.
  • The teen’s eating has been extremely restrictive and the range of foods at the outset is extremely small
  • There is concern about medical issues such as refeeding syndrome and intake must be more closely measured
  • There is a history of an eating disorder in a parent and they feel insecure about challenging their child’s eating
  • The parents are highly anxious and unusually overwhelmed and benefit from greater support and direction from a dietitian.

Towards the end of Phase 2, I find it very valuable to have the dietitian begin meeting individually with the teen. This can be helpful in trying to increase the teen’s responsibility for their own recovery. The dietitian can also bridge the gap between the parents being in charge and the child being in charge by temporarily overseeing the child as the parents relax control. We have found it very beneficial for the dietitian to help the adolescent work on determining portion sizes and exposure to fear foods and eating in different contexts and to have some initial meals without the parent and see how they do.

Individual Therapists

Resources are limited: families have limited finances and there are not enough eating disorder providers to meet the demand of people with eating disorders. I believe that in most cases we should wait until Phase 2 of FBT before adding additional therapies. In this way, we can see what issues resolve on their own when weight is restored. After a teen has resumed regular eating and has nutrition sufficient to support higher level brain functioning, individual therapy can be added if it is needed. This is the point in therapy at which the adolescent is likely to be more receptive and able to benefit from individual therapy.

Having worked alongside several individual therapists providing individual therapy while I provided FBT, I have some suggestions that can help keep all providers on the same page and maximize benefits to the family. The most common scenarios I have encountered include the following:

The biggest problems I have encountered occur when individual therapists focus on coaching the adolescent to individuate and stand up to parents. This is inconsistent with the early stage of FBT, which requires the parents to be empowered to make all food decisions for an adolescent who is incapable of making reasonable decisions about food given their brain starvation. In FBT we don’t encourage independence in eating until the teen shows they can handle it. Similarly problematic are providers who educate the adolescent about his parents being too “enmeshed.”

On the other hand, I have had great experiences with individual therapists who understood that keeping the parents in charge of eating was crucial for the teen’s recovery. Instead, these therapists worked to empower the parents to help the teen eliminate other obsessive behaviors such as compulsive exercise. I have also worked with successful  DBT teams that focused on teaching the adolescent skills to manage their distress while not attempting to question or undermine the parents’ authority over food decisions.

Advice for The Individual Therapist

My advice for the individual therapist:

  • Don’t blame parents for causing ED
  • Don’t disempower the parents
    • Don’t question parents being in charge of food
    • Don’t suggest compromising on food choices
  • Don’t describe parents as enmeshed—instead, reinforce their instincts in attending to a very ill child
  • Don’t focus on empowering the adolescent to share frustrations about parents being in charge
  • Do focus on empowering the adolescent to demonstrate recovery behaviors even if it is for show (“acting as if”)
  • Help the adolescent to develop coping skills to use when the FBT process is upsetting to them
  • Respect parents’ choice to stop activities until they eat (delineate consequences before meals)
  • Help the adolescent fill their life with other things
  • Remind the adolescent that the parents will be able to give back control as the adolescent demonstrates readiness
  • Let the adolescent vent about their frustration over parents being in charge
  • Acknowledge that although there are many things the teen can do on their own that are developmentally appropriate, at the present time eating independently is not one of them

 

Categories
body image Dieting

Sweatin’ for the Wedding: Say, “I don’t.”

Image by rawpixel on Pixabay

by Carolyn Hersh, LMFT

In November of 2018, my boyfriend proposed to me. It was one of the most exciting days of my life thus far. With a proposal comes the next exciting chapter: wedding planning. For many brides-to-be, this entails finding that perfect gown.

Sadly, although not surprising, once I got on bridal mailing lists, I learned I was also being targeted by gyms for “Bridal Boot Camps” and “Sweatin’ for the Wedding.” The weight loss industry found yet another way to weasel their way into a life event that should have nothing to do with changing one’s body.

Why is it that you could be with someone who you love for a certain amount of years, and suddenly the moment they place a ring on your finger you need to change your body? Why does looking beautiful equate to weighing less?

Unfortunately, it has become the norm in our culture to experience pressure to lose weight for special events. A friend once shared that when she was dress shopping her consultant actually wrote down smaller measurements because “all brides lose weight.” When my dress consultant mentioned letting her know if I lose weight, my initial thoughts were, “Are you telling me I need to lose weight? Am I supposed to lose weight? What if I like my body where it is? What if I want to gain weight?”

Granted, our bodies can change. But, hearing about weight loss, exercise programs, and diets specific for the big day can be detrimental to our physical and mental health. The diet industry has found another market and doesn’t care how it impacts the people getting married.. Wedding planning can be stressful enough with trying to create a special day without the added pressure to create a “perfect” body.

But, here is the thing. Your fiance asked to marry you not because of what you’ll look like on that one specific day, but because they are in love with you and everything about you. Getting married is about making a commitment of love to one another. Your wedding day should be a celebration of that.

As brides or grooms, we should dress up and present ourselves the way we want to on this day but, it should not be at the expense of our health and well being. Remember what this day is about. Your wedding is not about the celebration of the size of your body but about the love between you and your significant other and making a commitment to one another.

What to do Instead of “Sweatin it”

Here are some tips I have developed to use myself and also with my clients who were wedding dress shopping:

  1. Buy a dress that fits you now. Don’t buy something a size smaller. Don’t use words like “my goal size” or “I’ll be pretty when I fit into this.” Fighting your body to go to a size it isn’t meant to be is only going to add more frustration, stress, and sadness. If the person selling you a dress keeps harping on “when you’ll lose weight” or “all brides lose weight” speak up and tell her that isn’t your plan. You do not have to be a victim of diet culture. Buy the dress that makes you feel pretty right now. Also, do not forget that many dresses you try on are just sample dresses. It’s okay if it doesn’t fit perfectly when you try the dress on. The one you get will be tailored to your already beautiful body,
  2. With that, remind yourself of the things that not only make you look beautiful but what makes you feel beautiful. One of my bridal consultants asked me when picking out a dress, “Do you want to feel whimsical? Do you want to feel like a princess? Do you want to be sexy vixen?” Wedding dress shopping became ten times more fun when I could close my eyes and imagine what style of dress would make me feel the most beautiful.
  3. Write down what you want to feel on your wedding day. Write down your hopes and excitements for this day. Think about what memories you want to hold onto.  While the idea of “looking perfect” in your wedding photos may be a strong drive to engage in diet culture, think about what those photos are truly capturing. Most likely, you’ll want to remember this as a day of celebrating love and new beginnings with your partner.
  4. It’s okay to exercise and it is okay to eat. It’s okay to follow your normal routine, As you plan for your wedding continue to follow your intuitive voice. For many people, weddings take months if not years to plan. Do not remove fun foods out of your diet for the sake of just one day. Listen to your body when it comes to exercise. Exercise because you want to give your body the gift of movement, but know it is okay to take days off too. Exercise should not be a punishment to your body.

In Conclusion

You do not need to lose weight for your wedding day. Ultimately, remember what this day means to you and your partner. Your wedding dress should be the accessory to the already amazing you. You know, the person that your partner wants to spend the rest of his or her life with. So, when it comes to “sweatin’ for the wedding,” say, “I don’t.”

Categories
Eating Disorders

Weight Gain in Bulimia Recovery

by Elisha Carcieri, Ph.D., therapist at EDTLA

Dall.e

One of the hallmark features of eating disorders is placing a high value on body weight and shape in determining one’s self-worth. In addition, people with eating disorders often believe that body shape and weight can be controlled through diet, exercise, or, in the case of bulimia nervosa, purging. Individuals with bulimia nervosa purge in an attempt to eliminate calories consumed (which is actually ineffective), empty or flatten the stomach, modulate mood, or as a self-imposed negative consequence for binging. Bulimia carries serious mental and medical health risks. The road to recovery from bulimia usually involves (at least) outpatient therapy with a qualified mental health professional such as a psychologist.

Bulimia Treatment

Cognitive behavioral therapy (CBT) is the most well-researched and effective treatment for bulimia. Therapy begins with an initial goal to immediately stop purging, monitoring weight and food intake and implementing regular eating, which usually looks like three meals and two snacks spread out over the course of the day. Over the course of therapy, the patient and therapist address the various factors that keep the eating disorder going including the over-evaluation of weight, shape, and one’s ability to control these factors, dietary restraint and restricting food intake, and mood and anxiety-related factors associated with the eating problem.

Most patients with bulimia nervosa present to treatment at a weight that is in a “normal” range for their height. This is in contrast to those with anorexia nervosa, who are typically underweight. Despite being at a normal weight, the characteristic weight and body dissatisfaction associated with bulimia is strong at the beginning of treatment, and patients believe that they are controlling their weight via their purging behaviors. People with bulimia often restrict food intake in various ways, only to eventually binge and purge. Because treatment involves eating meals at regular intervals without purging, a common fear at the outset of treatment is whether changing eating patterns will result in weight gain. The answer is…maybe.

For most patients with bulimia nervosa, treatment will not result in a significant change in weight. However, some patients may gain weight and a small percentage of patients will lose weight as a result of eliminating binge eating. It is not advisable for patients in recovery from an eating disorder (or anyone, for that matter) to have a specific goal weight in mind. Focusing on weight loss is incompatible with CBT strategies to eat balanced and sustaining meals at regular intervals. Weight may fluctuate over the course of treatment, and, when a person is eating normally, the body naturally gravitates toward a biologically determined weight that is largely out of our control. Indeed, learning to focus less on body weight as a determinant of achievement or self-worth is a valuable treatment goal.

What is Weight Suppression?

Some patients with bulimia may start treatment at a weight that is in the normal range for their height or even on the high side but low in the context of their adult weight history. Weight suppression is maintaining a body weight that is lower than an individual’s highest adult weight. Recent research has begun to shed light on the effects of weight suppression on eating disorders, especially bulimia. Bulimia is often kick-started with a desire to lose weight and attempt at weight loss through dieting. Research has demonstrated that living at a suppressed weight has a significant impact on bulimic behaviors, increasing the likelihood of binge eating (potentially through a brain-based biobehavioral self-preservation mechanism), and subsequently purging. Relatedly, and counterintuitive to what people with bulimia believe about their ability to control their weight, weight suppression is associated with weight gain over time, which further promotes dieting and purging given the strong aversion to weight gain that most sufferers experience.

Will I Gain Weight?

So, what does this mean for treatment and recovery? For patients seeking treatment, this means that yes, you may gain weight, especially if your weight is lower than a previous higher adult weight. This may feel scary, especially at first. Clinicians may even feel uncomfortable having this discussion and feel tempted to reassure patients that they will not gain weight. However, this message is inconsistent with what we now know about weight suppression and reinforces the idea that gaining weight is to be feared and avoided at all costs. Gaining some weight may actually be the key to breaking the cycle of binging and purging, which is much more valuable than maintaining a lower weight.

Greater weight suppression is associated with persistent bulimia symptoms and relapse, so gaining some weight may actually increase the likelihood of recovery from bulimia and also serve as protection against future eating disorder relapse. Weight gain may not just be a side effect of treatment, but it may be an appropriate treatment goal if you have bulimia and are living at a suppressed weight, just as it is an important goal for someone recovering from anorexia.

In Conclusion

If you have had previous treatment, but are still binging and/or purging, it is important to explore whether weight suppression might be a contributing factor. You can discuss whether gaining some weight might be appropriate with your clinician. Understanding the role of weight suppression on maintenance of the eating disorder should serve as motivation to continue treatment and work toward managing negative feelings related to weight gain. Indeed, it is helpful to explore the motivation behind the importance of thinness or maintaining a certain weight and challenging fears associated with gaining weight. You may find that living at a slightly higher weight, once acceptance is achieved, can be much less stressful and time-consuming than forcing your body to weigh less than it is biologically programmed to.

References

Fairburn, C. G. (2008). Cognitive behavior therapy and eating disorders. New York, NY: Guilford.

Juarascio, A., Lantz, E. L., Muratore, A. F., & Lowe, M. R. (2018). Addressing weight suppression to improve treatment outcome for bulimia nervosa. Cognitive and behavioral practice, 25(3), 391-401.

Lowe, M. R., Piers, A. D., & Benson, L. (2018). Weight suppression in eating disorders: a research and conceptual update. Current psychiatry reports, 20(10), 80.

 

Elisha Carcieri, Ph.D., is a licensed clinical psychologist (PSY #26716). 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 is also a proponent of 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. She is currently living in Charleston and working as a full-time mom to her two sons, ages 3 and 1. Dr. Carcieri is a member of the Academy for Eating Disorders (AED). She can be reached via email at ECarcieri@EDTLA.com

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