Adolescence: a Risk Factor for Eating Disorders: Revisited

Here is a post from 2014 that needs to be revisited:
Adolescence is a time of physical, mental and emotional growth. The rate of internal change is so fast that mistakes of poor judgment are inevitable. In fact, one of the last parts of the brain to mature involves planning and judgment, qualities clearly lacking for most teenagers. Combine this decision-making difficulty with the penchant for exploration and much of the risk for teenagers is perfectly clear.

In every generation, there appears to be a new, tantalizing frontier that transforms into a universal rite of passage for adolescents. Alcohol, drugs and sex are the three most common concerns, but others have crept in like prescription pills and self-harm such as cutting.

One of the newest adolescents crazes is the drive for thinness. With the expectation for both boys and girls to have unnaturally thin bodies, especially unnatural during the hormonal shifts of puberty, the appeal of weight loss has grown into a standard experience for teenagers. Peer pressure to restrict food, purge meals or take pills such as Adderall, laxatives or diuretics have grown almost unavoidable. Kids can find any number of weight loss guides on line as well to steer them towards these dangerous behaviors.

The thrill of seeing an effect on one's body can be exhilarating to a teenager who feels like life is an out-of-control roller coaster. The sense of pride and accomplishment, albeit one that is small and in the long run meaningless, quiets the constant feeling of confusion and replaces struggling self-worth with an immediate burst of confidence.

It's scary to reflect on just how powerful the drive for weight loss can be in adolescence and how success feels downright magical.

As with all of the destructive behaviors for teenagers, the long-term risks always escape their notice. Engaging in eating disordered behaviors, especially restricting food, sets off a cascade of biological and psychological responses to starvation.

No one can predict how each child will respond. No one knows if that child will just give up after a day or two, get caught in a cycle of restricting and overeating or be genetically susceptible to develop anorexia. But the increasingly common exposure to starvation for teenagers means those kids are more and more likely to find out.

Until recently, no one would even consider these risks for a child. Eating meals through the day was a matter of course and the drive for thinness nonexistent. Accordingly, the incidence of eating disorders was very small, a rare and mysterious disease people fell into without any idea what was happening. That's not how eating disorders develop anymore.

Adolescence has become a breeding ground for eating disorders, replete with friendships encouraging the behaviors, online groups dedicated to provide support and the social normalization of irrational food restriction. Just as drinking or using drugs at a young age can set that child up for much larger problems, food restriction increases the risk of developing an eating disorder.

However, parents and adults are much less likely to worry about a teenager dieting than about using drugs. Those adults may themselves be restricting food or even encouraging the child to eat less. The social norms actually span generations, leaving teenagers without any idea their behavior is dangerous. The general obsession with thinness leaves children at sea to find a sane way to understand food and weight.

With teenagers dieting and engaging in eating disordered behaviors, there needs to be a public health campaign to counter the false advertising of the food and diet industries. More specifically, children need to understand the risks of their behaviors and the expected norms that will keep them safe.

Adolescents won't necessarily follow the rules because that's the nature of the stage of life. However, exposure to the risks and norms will at least offer them some guidelines to either heed or ignore. It will allow them to know when their decisions are leading them into trouble. It will also give parents, even those struggling with food and weight, a means to teach their children a saner attitude about their bodies.


True Recovery is about Living a Full Life

Since the majority of eating disorders start during adolescence, the illnesses interfere with emotional and psychological development. Just at a time when children begin to learn about their own identity and how to interact with others in a more mature way, those first diagnosed with eating disorders start out their lives devoting energy to treatment.

The time spent in therapy learning about themselves and their emotions actually may land them ahead of the curve of this part of becoming an adult, even if the path is an unusual one. But that’s only the case for the lucky ones who recover quickly.

Others who remain sick and take longer to get well can spend many of their formative years in programs that can help them try to get well but also encourage regression in a setting aimed at recovery and not the personal growth that is the hallmark of adolescence.

The process of treatment over time can inhibit some people from feeling empowered to face the realities of becoming an adult. So much of this time of life is about finding courage to face new, challenging experiences and learning how to manage all different outcomes. For people with eating disorders, the treatment world often becomes too comfortable and transforms into a convenient way to avoid life.

Although treatment needs to provide an environment that is safe and promotes recovery, it also needs to encourage people to engage in their lives and to challenge them to participate in the world. Too often, clinicians recommend opting out of school or work for extended periods of time when there is no evidence that doing so necessarily leads to more complete recovery. For adolescents and young adults, the new world of treatment can quickly become the world they choose and find comfortable. Although treatment is often necessary, decisions about long term help need to take into account the goal of fully reintegrating into that stage of life.

The goal of treatment is not just to quell the eating disorder symptoms and return to full health. The idea is to get right back on life’s path and find a full life again.


Respecting People with Eating Disorders

The role of mental health treatment in the world of people with eating disorders is complex. For those who clearly are seeking wellness and recovery, traditional therapy is the best alternative. Mental health practitioners act as a source of support and treatment to help that person create a path out of the eating disorder.

What about the people not looking for recovery who still want support? Even more critically, what about the people completely outside the treatment world not interested in the professional help available?

The standard approach for many clinicians is to label these people as either in denial or intractable. The implication is that they cannot be helped and need to find their own motivation first. It’s even acceptable for clinicians to end treatment because the person supposedly isn’t ready.

This categorical approach to the idea of treatment seems very punitive to me. Why should people be rejected, judged or criticized for doing their best with a very difficult illness? Shouldn’t their plight elicit compassion and not judgment?

Another complaint patients often have is that clinicians feel entitled to tell patients how well they ought to be. Although recovery is an option for people sick with eating disorders, and for many the goal, clinicians have to accept that many people remain in their eating disorder and need someone to meet them where they are. That’s not easy for clinicians to do, but it establishes necessary respect if therapy can have any benefit.

The increased power of residential treatment companies also encourage the mindset that wellness is the only option and that residential treatment is the only path. It threatens to limit to full scope of treatment options and label everyone else as unmotivated.

Clinicians who treat people with eating disorders need to be cognizant of the limitations of eating disorder treatments and to be open to all forms of treatment and life paths. Flexibility, humility and openmindedness make the best clinicians to help people struggling with eating disorders. 


Why Medications are so Ineffective for Anorexia

When someone, clinician or layperson, begins to understand the underlying thought process of anorexia, it becomes hard not to see the illness as a fundamental problem in brain function. The medical consequences of starvation make clear that anorexia is a physical illness as well, but the tortured thoughts of the disorder are the most shocking revelation.

The overall treatment plan for anorexia is a treatment team covering all the possible bases: therapist, psychiatrist, dietitian and primary care doctor. Sometimes, attention to the details of recovery and improved nutrition are enough to start reversing the course. Frequently, they are insufficient.

Consequently, it’s reasonable that patients and families turn to psychiatric medication as a possible salve for the psychological wounds inflicted by anorexia. There must surely be a medication that can reverse the nonsensical and distorted view that food is not meant to be eaten and that weight loss is paramount no matter the cost.

The psychiatric community agrees with this assumption. Despite the utter lack of success of any medication and the ignorance of an underlying biological cause of the illness, psychiatrists continue to study any medication for its utility in the treatment of anorexia. Even though all studies have thus far have been futile, desperation for more effective treatment is the driving force for continued clinical research.

As of now, the most salient fact about the cause of anorexia is that genetics account for over 70% of the likelihood that someone develops the illness. There needs to be an initial trigger of starvation in order to assess how someone is programmed to respond to a lack of food.

In our society currently, sanctioned dieting, even for children, allows many communities to serve as breeding grounds for eating disorders. The mere acceptance of dieting as a reasonable decision puts adolescents and adults at risk regularly. Prior to the practically universal acceptance of dieting, eating disorders barely existed in our communities.

Survival is the body’s primary ingrained response to starvation and surely is an adaptation that enabled ancestors not lucky enough to live with an overabundance supply of food to persist. It’s unlikely that there is a pharmaceutical fix for a longstanding genetic adaptation.

Although the crucial step to decrease anorexia and eating disorders is to stop sanctioned dieting, it’s more likely that we can create an environment that helps someone already sick to constantly question the anorexic thoughts. When a trusted clinician combined with the person’s support network repeat that the eating disorder thoughts are lies and only hurt them day after day, week after week, month after month, recovery can be possible. Yes we need more options, but medications aren’t likely to be the solution.


Management of a Chronic Eating Disorder

One topic i have not addressed more clearly is the person who has no true interest or ability to consider full recovery. The idea that people with eating disorders are sick forever is a common misunderstanding in today’s culture. In fact, it is still surprising for many lay people to hear that recovery is even an option, let alone something that occurs on a regular basis, albeit over a period of time and with very difficult, often excruciating work.

Realistically, many people do live with eating disorders for their entire lives. Many of them get professional help, but with the purpose of seeking emotional support from a knowledgeable clinician and perhaps guidance how to manage the illness and still function in life, not to get well. 

The distinction between treatment intended for recovery and management of an eating disorder is significant. As opposed to full treatment, eating disorder management has very different goals: containment of medical conditions associated with the illness, emotional support for the daily struggle of surviving an eating disorder and education about improvements in eating that will manage weight and health within the guidelines allowed by the eating disorder.

Many clinicians refuse to work with people who will not commit fully to recovery. So most of these patients have been ostracized and left to feel alone in their predicament. It’s a mandate for the clinical eating disorder community to commit to helping these people. They shouldn’t be punished because of our lack of effective treatment for the sickest people.

More than anything, people with chronic, intractable eating disorders need compassion. They did not ask for this horrible illness. Many of them have endured long stretches of available treatment with minimal benefit. They deserve kindness and thoughtful care to help them live the best lives available to them. It’s hard to completely ignore my optimistic thought that even in these circumstances, at least partial recovery, if not more, may still be possible. The next post will discuss treatment of these patients more specifically.


The Pros and Cons of Eating Disorder Treatment Teams

The standard of care for an eating disorder, if someone doesn’t need residential or hospital care, is to assemble a treatment team. This involves several components: a therapist, a dietitian, a primary care doctor, a psychiatrist (frequently but not always) and a set of other possible options such as meal support or group therapy.

This team covers all the bases and provides treatment for all different aspects of recovery. It’s almost dogma for clinicians to automatically suggest assembling a team and for many people doing so leads to progress.

However, there is a reflexive element to this process; as if the team itself somehow creates an illusion that recovery and wellness is easily within the grasp of all patients. The reality of eating disorder treatment consistently shows that not everyone gets well quickly and not everyone gets well.

This advice also serves another purpose: to insulate practitioners from responsibility if treatment doesn’t go as planned. Since the team approach is the standard of care for people with eating disorders, it’s easy for treatment providers to tell themselves they did their part. They were part of the team or recommended assembling a team. If the team didn’t help, tacitly blaming the patient is an easy option to fall back on. 

For people early in their treatment, working with a team makes sense. Exposure to all types of eating disorder clinicians will help someone find what works best for them.

After this introductory period, individualized treatment is crucial. Continuing to suggest the exact same thing for someone who already has tried that path with limited benefit deserves more thoughtful care.

It is the responsibility of the clinician to think outside the box for different ideas to help. Relying solely on the standard care only shows a lack of creativity and frankly a lack of caring. Since eating disorder treatment is far from perfect, patients need to know all possible elements of treatment are on the table and that the people in their corner are doing everything they can to make a difference.


The Unfairness of Eating Disorder Recovery

It’s a fine line between blame and responsibility when it comes to eating disorder recovery. I wrote the last post with trepidation that it was too easy to interpret my words as blaming the patient for their illness, something I adamantly oppose.

And certainly the same logic wouldn’t apply to a purely physical illness such as cancer.

Part of the difference lies in the core medical knowledge and treatment options. The science of brain function remains in its infancy. Only a few decades ago, a common misconception was that people only use 10% of their brain, but that factoid reflected justification for our collective ignorance. Even as we learn more about how our mind works, the yawning scientific gaps preclude the large majority of any truly functional knowledge.

However, the medical information available about cancer is also very limited, as is treatment. Why is the discrepancy in attitude towards eating disorders as opposed to cancer so wide?

Cancer is an invasive “other” in one’s body. The psychological component of treatment is one of endurance and maintaining optimism in the face of so much fear and doubt. The goal of treatment is very clear. There is no way for the doctor-patient relationship to be adversarial.

Eating disorder treatment attempts to separate out the eating disorder thought process from one’s own independent thoughts. Although that construct is useful and effective, it is a construct nonetheless. Eating disorder thoughts may be the driver of the illness, but they still feel like one’s own thoughts. The cognitive exercise of learning to identify them as part of the illness, dismiss them and follow a different, often newly acquired set of thoughts is challenging at best.

When an educated, caring, well-meaning clinician urges week after week the patient to follow these new thoughts and ignore a well-worn pattern of daily life, inevitably there will be friction in the treatment. The process of learning new patterns with food and managing the concomitant thoughts is challenging and bumpy. Since no treatment can effectively ease this painful transition, that responsibility to work on new behaviors each day has to lie with the sufferer.

This is certainly a cruel joke. Not only is someone saddled with an eating disorder but the only effective treatment option is a slow and painful struggle against the powerful eating disorder forces. And it’s easy to see why not everyone can get well.

I am always searching for new ways to make this easier, to prevent the suffering and to sidestep the prolonged pain of the process. I remain hopeful because many, many people do get well. In the meanwhile, I also have to accept these realities and communicate them in treatment.