Restricting causes bingeing

I'm really not sure how I made it this far in this blog without more directly addressing this topic. And, I know I have referred to it in a couple other posts, but this is such a key concept that so many people...patients, family, and providers alike....just don't understand. And, fortunately, it's a very simple concept also.

I recently had another provider give me the most brilliantly phrased psychological assessment of a patient. I was blown away by the providers ability to phrase a summary of the patient's treatment, and the psychological explanation for the patient's bingeing, which I will admit was likely right on. There was just one important variable missing for this provider, and in my experience, for many providers, when it comes to helping patient create behavior change around binge eating behaviors.

What this provider was missing was that the patient was restricting all day long, and bingeing at night. And, this is what most people do, in my experience. Dieters do it, and those with eating disorders do it. They tried to make it as long as possible during the day without eating, but then the physiology of all that catches up at night, and the person ends up overeating. And they think this means they have no control, no willpower, that they are weak; and their provider may think it is some emotional trigger that causes this behavior. But, as long as the person is restricting, that should be assumed to be the "cause" of bingeing or overeating. How we explain it to patients is that we must correct the physiology first, and then we'll have a better sense of what is psychological. So, in this case, we see that most bingeing behaviors are corrected by eating more throughout the day, but of course, there are then psychological factors such as stress or anxiety that result in ongoing overeating; that is when therapy really comes into to address those factors.

But if you miss the fact that someone who is binge eating is also restricting (and in our experience, the vast majority do), a provider, or the patient, can end up looking for psychological explanations, and pursuing those routes, only to result in greater frustration that the behavior continues.

Of course, as I have referenced before, the trick is that many who binge eat don't want to stop restricting. They are afraid of weight gain and don't want to take the risk of that happening by eating more during the day. But, in the end, the "math problem" tends to balance out; the amount of calories consumed by eating more during the day is about the same as, or even less then, the amount eaten as a result of restricting and then bingeing. Eating regularly during the day is also of significantly greater benefit to one's metabolism also, whereas restricting can really only result in decreased metabolism. Your body cannot burn what is not there to burn, so it's only option is to burn less.

So, the main thing I would want binge eaters to understand is that their behavior is NOT the result of low motivation, laziness, weakness, lack of willpower, etc. That is the "easy answer," but in my experience, never the right one. No matter how much our society might say it is true. And, to be clear, restricting is also not a sign of strength or willpower, even if it may feel like it for the moment. Treatment is the sign of strength and willpower. I do not work with a single weak person, that is for sure.

More on body image

If it is indeed true that body image is one of the last things to change, imagine the experience of going through eating disorder treatment. Patients would, logically, want to feel better about their body so they can feel better about changing it, right? But it just doesn't work that way. So, what patients are asked to do is very hard indeed.

Patients are asked to put their appearance as a lower priority than their health, or their future goals. I wish I knew of a way to make it so they liked their body. And of course there are plenty of messages in our society that if we just change our body, we will be happy, healthier, probably even wealthier. What a misleading message. In reality, focusing on our bodies makes us unhappier and less healthy, both physically and psychologically. But, that simply is not how it seems in the moment.

Families and friends often come in, valiantly trying to rationalize with their loved one about their body. They try and try to convince their loved one that what they see in the mirror is not what is reality, and/or why do they have to care so much about their weight. And this is where it is important to be reminded that eating disorders are not rational diseases, and thus, unfortunately, rationalizing often has little to no benefit, and instead serves to frustrate everyone involved.

So, this bears the question: What do we do instead when our loved one is so upset about her body? Try to remain non-emotional and avoid the frustration. Assume what he/she is saying is what he/she really sees and/or believes, and put yourself in that position. It doesn't mean you agree with what they are saying or thinking about their body, and you can certainly say you do not agree. But, let them see you can understand, as best you can, just how much it hurts to believe what they believe.

Maybe ask them if there is any part of their body they do like; I often jokingly reference the big toe just to make the point that there is maybe some small part of their body they might not hate. And, yes, toenails has been an answer before. What about any part of their body they can value in some way other than appearance. For example, in my experience, many female athletes HATE their legs. They see their muscle as fat, or fear that others think their muscle is fat. But, they often can recognize they also value the strength of their muscular legs.

Also, help your loved one talk about whether they can make anything else more important than their appearance. Are there any situations where they forget, for even a second, about their body? Admittedly, these are often conversations that seem to go better in therapy than at home, so don't become upset if these topics don't seem to help.

Finally, look at yourself and things you perhaps unconsciously say or do. Be aware of whether you, or any other family or friends comment about your own appearance, or anyone else's. Work to change any family patterns around food and weight that unintentionally reinforce an eating disorder. Our society reinforces eating disorders ALL THE TIME, so of course families in our culture do. It's not about blaming the family, or even the culture; it's about understanding what change could help.

Body image concerns are so confusing to those who do not see themselves in such a critical and irrational way. But, coming to understand what your loved one does see can really help you support them in changing it.

Separating the eating disorder from the person

Patients will come in, and some will joke in an embarrassed way that they sound like they have schizophrenia (though they usually call in multiple personalities). They are able to identify that there's this separate voice in their heads, telling them what to do with food. They do not have schizophrenia. I think Jenni Schaefer, in her book Life Without ED is the first person (that I know of) that really clearly put into words the separation between the person and the ED. And this is such an important distinction. Lock and LeGrange, who have really advocated and research Family Based Treatment (aka Maudsley Method), have also emphasized that parents needs to make this separation in order to best help their child with an eating disorder.

But, this is a hard separation. We all know that. In the moment when the ED is acting up, it is happening in the body of the person you love. And, let's be honest, some moments you want to yell at them, scream at them, shake them, and perhaps wring their necks! (It's okay, you can admit it). So, most parents/loved ones do indeed end up yelling, screaming, and threatening the person they love who has an eating disorder.

But, the patient on the receiving end of all this, kind of has two choices at that point. Okay, three, but #3 is a bit of a huge feat to accomplish.

• One, they can fight back, and essentially further embody the eating disorder. They can yell and scream and stomp their feet, which only serves to reinforce the idea that he/she, the patient, is setting out to torture those around him/her. 
• Two, they can take the anger in, blaming him/herself for being a "bad person," which again, gives the ED more power. 
• Three, they could assume the very, very best of their loved ones, be able to understand they really are mad at the disorder, not them, and choose to fight the disorder with their loved one. Sounds great, huh? 

I'm a parent, okay stepparent, of a teenager, and I'll easily confess that, at times, strangling her has seemed a viable option. So, there you go, even the psychologist admits that even she cannot do what she is about to say flawlessly. But, in the end, strangling someone doesn't really accomplish much, right? So, what do you do instead?

You separate the disorder from the person. You realize the person is in a battle with that voice inside his/her own head, and doesn't like the battle any more than you do, though some days he/she is more convinced that voice is right than wrong. So, some days, he/she may not join your "team" as much as she might the next day. But, if you can remember it is you and your loved one against a terrible disorder, then hopefully you can each get mad at the disorder. I promise you, the person is also mad at the disorder; it has taken away things that are important to him or her. But, she still is likely to respond to you in anger if you get angry at her. I want to be clear, I am not saying be soft, be lenient, let things slide. Those of you who know me are laughing right now because you KNOW that's not what I mean. Be very hard on that disorder, fight it with all you have. But don't fight the person, fight the disorder. You are more than welcome to despise, hate, want to destroy the disorder. Just as you would if your child had cancer. But, just as you wouldn't yell at your loved one for having cancer, try your hardest not to yell at your loved one with an eating disorder. 

The Mask

This is a poem, written by Anonymous, that I used to always read when I provided lectures on eating disorders:

Take a look at my face
What do you see?
A woman who shows you
What she wants you to see.

Hear my spoken words
what do they say?
Only what I want you to hear
It's better that way.

See my ongoing smile
What does it show?
Only a small part of me
That I want you to know.

Hear my witty responses
Do they make you laugh?
That satisfies a small hunger
 to be accepted at last.

The feelings I express
Do you think that I"m strong
It's what I need you to think
and again I press on.

If you looked deep in my eyes
It's what I can't let you see
The most incredibly fear
That's strangling me.

If you heard all my thoughts
That I can't let you know
Of shear desperation
That's threatening to show.

If you saw behind the smile
That at this point's painted on
Because my heart's slowly breaking
All security's gone.

My casual wit
A facade nothing more
That once came to ease
Is now such a chore.

If I let you know
Just what makes me tick
I'd lose all control
It's too much of a risk.

So you'll know me best
As who I wish I could be
Someone strong and courageous
really so unlike me.

The poem is sad, but I think accurately represents what those with EDs feel like when trapped in the disorder, partly wanting to hide, and partly wanting their pain to be seen.

However, I must disagree with the last two lines. Fighting an ED requires a ton of strength and courage. Just this morning I watched the internal battle of a young woman who has the "anorexic wish:" Please help me get better without gaining weight. It is anything but weakness that one sees in someone fighting an ED.

Binge eating disorder: the overlooked eating disorder

I was thinking about what to post, and realized I think my own blog represents the ways in which binge eating disorder is overlooked. Sure, so it's not an "official" eating disorder yet. It will be, and regardless, it is something with which many of our patients struggle. It reminds me of the post on competition between the eating disorders. I guess I don't often hear someone with binge eating disorder say they wish they had anorexia, but it wouldn't surprise me if the thought process is there.

I think the vast majority of our binge eating disorder patients don't even recognize their disorder is also fraught with restriction. The typical pattern for binge eating that I see is restriction in two different ways. One, there's the long-term restriction of multiple diets throughout their lives. Then, there's the day-to-day restriction, where they do not eat enough during the day, and then binge at night. But, in my experience, binge eaters look at their own body size and think both that they don't "deserve" the label of an eating disorder (because only the emaciated REALLY have eating disorders), and they cannot possibly restrict. So, at the beginning, it is often a bit of a battle on our parts to help those with BED recognize they are restricting.  But they must recognize this as they likely will not stop bingeing if they do not stop restricting.

A couple of themes that have come up with those who binge eat and/or compulsively overeat and, as a result, are at a higher weight. First, they often refuse to go to doctors anymore because, as they say, "I don't need anyone else to tell me I need to lose weight. It's like they think I'm not aware I weigh what I do." Second, almost without fail, these patients have a very limited ability to show any emotion. A few recently have talked about this concept in being "the funny, fat friend." They report feeling pressure to show everyone how funny they can be, seemingly to compensate for their weight.

We have struggled and struggled to start a binge eating group. I may have commented before on the difficult nature of trying to run any type of eating disorder group, given all the comparing and social anxiety. But, my guess is that the shame has been so strongly instilled in those with binge eating disorder, especially those at higher weights, that they just suffer in silence, not wanting to subject themselves to more judgement; even from those who suffer from the same behaviors. I remain optimistic that we will get a binge eating group started. I think it is greatly needed; especially so there can be a place where nobody needs to be the "funny, fat friend."

Ohhh, body image

Wow, body image. Such a difficult topic, in my opinion. I do think it is the very last thing to change in an eating disorder, which is really quite unfair. At the same time, I think there can be significant improvement in body image, both for physiological and psychological reasons, as ED behaviors stop.

Physiologically, we know from the Keys Study that body image concerns can be created from starvation alone. In short, the Keys Study showed that when they starved down totally normal men (this was for a completely non-ED related study, by the way), they developed dissatisfaction with their appearance. The men did not have EDs, but began to illustrate a number of behaviors we typically think as being caused by the ED. This study is the main thing that has illustrated that starvation must be addressed prior to, or at least at the same time as, working on the psychology of the ED, because many ED thoughts and feelings can improve with appropriate food intake and weight. In these men, weight gain alone corrected the body image concerns.

I have a colleague who developed cancer, and had to have chemotherapy. She lost a significant amount of weight, and one day, she looked at me and said she finally understood the body image part of eating disorders. She told me that, before she got cancer, she was satisfied with her appearance and weight. However, after losing weight, she found herself reticent to regain weight, though recognized this made no sense. So, this example also demonstrates how starvation alone causes body image concerns.

But, let me tell you, trying to convince a currently low weight patient that they will FEEL BETTER about their body as they gain weight....that's a pretty hard sell. And, it's not that they will LOVE their body. I have come to describe it this way: You will feel better about your body at that weight then you think you will at this weight. A confusing concept.

The other thing I noticed in working with patients with binge eating disorder was that, once they stopped bingeing, even when their weight stayed the same, they reported improved body image. I think this makes sense, because who can feel good about their body when they are subjecting themselves to any ED symptom.

So, how do I treat body image? Well, I guess I don't really. In those who need to gain weight, I guess I don't much see the benefit. As I explain to them, if I help them accept their weight during weight gain, they just have to keep reaccepting their weight. I think that would be maddening. I certainly know there is research evidence that some body image approaches help, but I guess I'm just not convinced they help enough, and instead may increase focus on one's body.

I think what has impacted me the most was one group I ran in a treatment center. I had asked the group members what they wanted to talk about, and they got me; they wanted to talk about body image. Aack! Somewhere in that group, I spit out a sentence I didn't think was of much consequence. I told the group members my personal approach to body image. It came out something like this:

     Sometimes, I don't like what I see in the mirror in the morning; but, then I look at myself, say, "I   
     have (bleeeep) to do," and head in to work to treat eating disorders.

My point with this was simple; that passions, goals, wants, interests, can outweigh what is seen in the mirror. If I stood there in the mirror and focused on how I looked, I would lose time doing my passion.

Now, I thought this was just one of those random sentences that comes out of my mouth. I was shocked when patient after patient came up to me over the next few months, saying this one random sentence really changed their view of body image. So, I guess that has always been my focus. Figure out what is more important than the image you see in the mirror. Sure, there are other things you can do....don't body check, pick out parts of your body you do like or value, stop the critical thoughts. But, more so, figure out what is more important....your appearance, or what you want to do with your life?

What things have helped you with body image concerns?

Insurance coverage for ED treatment

I see many an article, even a blog post, on insurance coverage for eating disorders and how poorly treatment is covered. I could write probably a more professional, appropriate post on this, but honestly, I'm not in the mood for such niceties. Below is the reality of being an eating disorder provider:

There's a young woman I care deeply for who is soon likely to die of her eating disorder. Now, certainly in the past she has had treatment and she has relapsed by making choices that were not consistent with her recovery. But, regardless, right now, her eating disorder is severe. Her body is shutting down, and she is going to die without expert intervention. She is currently in setting that is not able to manage her ED symptoms. Her insurance company is taking the "one program fits all approach" and refusing to give her any options for a treatment setting.

Mind you, this young woman is willing to go to treatment, she has signed herself into the current setting, she has remained in treatment without walking out. She is voluntary, and she is begging her insurance for options. The insurance company has heard from me, the patient, the family, the current setting, and we are all singing the same tune: Send this young woman to Program X, a program that is not that far away. They were supposed to have an answer last week, yet this week, she remains without any options, dying in her current setting.

I am irate. To worsen the story, this is the SECOND insurance company I have had to battle in this way for this patient. The previous company said, "She's a terminal case. She should just go to jail; that is a better setting for her." They refused coverage, I fought them. Let's just say they don't like me much anymore and I'm no longer authorized to see their ED patients. I will fight this second insurance company the same way. No amount of money from an insurance company will stop me from standing up to them to try to save this young woman's life.

I witness the emotional detachment others can demonstrate in these situations. Clearly, the insurance company is not seeing this young woman as a person. But, dammit, I know this young woman, she is not just a number, a paycheck, someone who chose this disorder. Until insurance companies, and even non-specialized providers better understand these disorders, we will lose patients. Insurance companies should not "be in bed" with one specific program and refuse to authorize other programs; that is just wrong. Not every patient will like me as his/her therapist, so there are multiple therapists to choose from; so why would they assume one program can serve all their members with eating disorders. This all makes me so angry. I know this young woman, and she does not deserve to die as a result of a breakdown of this system. She deserves one more shot at expert treatment. She deserve me continuing to fight, so I will.

At what point will people....providers, insurance companies, patients themselves....understand these disorders are lethal. They are not to be toyed with, brushed off, denied.

Fight your insurance companies. Hit them with more paper and more phone calls than they know what to do with. They are trying to wait you out, thinking you will back down; don't let it happen. Yes, they are a business, so they must be about the bottom line. But they also are a service industry, and they are serving you. You are paying their salaries. So, fight them. Please.

The "perfect patient"

Eating disorder treatment presents with a lot of ironies. They are often disorders of perfection, yet treatment sometimes demands perfection to save the person's life. For example, you need to eat exactly this, nothing more, nothing less, to make sure that we can keep you safe and out of the hospital. Ironic, huh? Never mind that the eating disorder is about over-focus on food and weight, yet what must (good) treatment focus on initially? Food and weight. I'm not sure there could be a more ironic field. Well, I guess sometimes in medicine, a similar thing happens. With cancer; here, take this lethal medication in an effort to save your life. Let's kill off all your body's defenses so it can defend itself better. So, I guess it's not just eating disorders, but it certainly is not the norm.

So, if eating disorders are about perfection, and some level of precision is needed at times during the process, what do you do with the "perfect patient?" These are the patients who come in and they want help on some level, but more so, perhaps, they want you to like them, accept them, approve of them. So, they tell you what they think you want to hear. Often times, they actually do the behaviors perfectly. For instance, they follow their meal plan perfectly, but they are not telling you that it is killing them inside. The outcome, in my experience, is that they gain weight, for example, or they stop bingeing and purging, or they stop whatever ED symptom, but the psychological parts of the disorder go unaddressed because they are showing you they are perfect, and are handling things perfectly. They are at high risk of relapse, as a result. And then they can't tell you about the relapse, because a relapse isn't perfect.

On the surface, it sure is nice to have a compliant patient. What a relief, right? Well, not so much. Because eating disorders are terribly painful diseases; they are hell to live with and to overcome. So, the process should not look perfect. Now, in that, I'm not saying that we should expect and accept non-compliance, because that won't help anything either. No, I'm saying that we need compliance, but honesty about horribly painful and difficult that compliance is. That is treatment. That is recovery. If your patient or your loved one is smiling at you about recovery from his/her ED, look deeper. Help him/her to talk about how it really feels to do what needs to be done in order to recover. In doing that, he/she relearns how to talk about all that he/she used her ED to avoid. As the ability to communicate returns, the need for the eating disorder decreases.

That is treatment. That is recovery.

Involving families in eating disorder treatment

Brie asked that I address the topic of involving families in the treatment process, especially for adult patients. I think this is something we do that is maybe a bit more unique. But, I also am somewhat blown away by the number of providers who treat children and adolescents, with and without eating disorders, without including the family. I don't see how that make sense. Therapy is one hour out of a week that has, ummm, 168 hours, I think. I just don't see how therapy alone will be powerful enough to override an eating disorder that resides in the patient's mind each of those 168 hours.

When it comes to involving family in an adult's treatment, however, there reasonably can be some hesitation. After all, adults don't want to feel like they have been rewinded to childhood or adolescence, and have to answer to Mom and Dad; this is fair! But, again, this disorder is lodged in the mind of the patient ALL THE TIME. It damages the individual's brain, and thus his or her thought processes, and rational thought suffers as a result of damage to the frontal lobe. I often speak of the vortex that exists right at my office door. When patients sit on my couch, it makes sense to give up their ED, stop the behaviors, and choose health. But, they hit that vortex, and get slammed by the world, and suddenly, that motivation and desire can wane.

So, here's where family and friends come in. But, it is key that the adult patient drive the family/friend involvement. They need to be able to tell their family/friends what they can do to help, and give them permission to say the difficult things the ED does not want to hear. Many patients will choose this path because it is the intervention that comes immediately prior to hospitalization; so, for those who do not want to be hospitalized, a good number will choose this alternative.

And, really, I think what most of us probably want is our family/friends' support anyway. When you have an ED, you tend to lose the ability to communicate as well, so it is harder to ask for that help. I have seen many patients feel great relief from being able to address their ED with those they care about in a safe environment, where a therapist can help the family to understand that the disorder is not rational and that, often, their gut reactions are not what is most helpful to the patient. I can write more on that at a later time.

Now, selfishly, as a provider, I will say that it is also helpful to have family and friends involved to help avoid unintentional undermining of what we are trying to do. If you think of the patient as having this totally separate voice in their head, the voice of the ED, and then the providers are trying to challenge the disorder; well, we are not always EXACTLY correctly quoted by the time the patient makes it home. In addition, with families being on the front lines of the battle against the disorder, they sometimes are more likely to try to negotiate with the disorder, perhaps saying a lower weight is reasonable, or that the patient doesn't need as much support as the treatment team recommends. If the family/friends are involved in the treatment itself, it provides an avenue where they can ask why we do what we do, and hopefully then feel more able to support our recommendations.

In short, EDs are terrible disorders that cause so much damage. The more people who can help treat them, the better. Families used to be banned from treatment because psychology LOVED blaming parents. Now, I think we all need to recognize that blaming parents has no benefit, but involving them in helping, when they are willing, can have incredible power.

Competition among the eating disorders

Reader Krista brought up this point of comparisons between those with eating disorders, and asked if she is the only one seeing that anorexia is glorified while bulimia is looked down upon. And, no, Krista, you are not the only one seeing this. I see it all the time and take a number of steps to try to avoid this in the group that I run, though certainly I understand I cannot change what is going on in each patient's mind.

I think the root of this is that our society glamorized dietary restriction. Which frustrates me to know end because I am very aware eating disorders are lethal; the most lethal of all psychiatric diagnoses. So, to have such a lethal behavior glamorized certainly shows the level of ignorance, but also just really irritates me, honestly! Those who restrict, whether in an ED or not, are seen as having control, willpower, strength, and power. Now, those with eating disorders generally know nothing could be farther from the truth. Sure, engaging in an ED can create a feeling of power and control at times, but most realize having an ED actually is a feeling of being out of control and powerless against the voice in your head.

Bingeing or bingeing and purging is simply not seen as as glamorous, so restricting is seen as the symptom of choice. In reality, those who binge and purge, the vast majority of the time, also restrict; that's the physiology that sets up the binge. But it is interesting how often those who binge and purge, and binge without purging, overlook their restricting because they feel such intense shame around the bingeing behavior.

Something that I think is also related is this concept of those with low weight eating disorders being able to use their body, their disorder, to communicate. Those without the low weight, I think, do not necessarily have that way of showing others that they need help, and so I think, for some, they may want that lower weight so that they are less invisible, ironically. This is just a thought on my part, nothing I have seen confirmed by research findings.