2/4/16

Decisions about Treatment for End-Stage Eating Disorder Patients

The legal component of mental health treatment is complex and has no easy answers. That is compounded several times by the decisions around end-stage eating disorder care. 

The medical complications of eating disorders are often life threatening. At the most severe stage of illness, multiple organ compromise or failure is common, but successful treatment eludes even the most experienced physicians who aren't knowledgeable about these diseases. Consequently, end-of-life care is often very poor. 

Usually, at this stage of any illness, the patient has some awareness of the medical situation and can either express their wishes or has already stated them prior to becoming so compromised. That is often not the case with eating disorder patients. 

The severe state of malnutrition typically strengthens the eating disorder thought process, so many patients in danger of losing their lives cannot understand the severity of the situation. The eating disorder mindset becomes so ingrained at that stage of illness that any other way of thinking is incomprehensible, even when physicians clearly explain the dire consequences. Moreover, the family is usually aware of the fact that it has been years since the patient felt that any change was possible, if ever. 

Ethically, what is the family to decide and what can physicians do? Emergency medical intervention, even against the patient's wishes, can save her life in the short run. However, long-term forced treatment has proven time and again to be counterproductive and only intensifies the grip of the eating disorder. Families can acquire the legal power to make decisions for their adult child but to what end?

These questions highlight the challenges of how to help such a severely ill person with an eating disorder in a life-threatening stage of the illness. The answers are all unsatisfactory, and the outcomes all look bleak. 

If the family can work with the patient and doctors to all agree to life-saving medical care then that is a reasonable first step. But pressing further treatment only feels like a prison sentence to any patient. Accepting the limitations of current treatment options is a crucial part of medical decisions making once a patient has multiple organ compromise.


Kindness, compassion and understanding can have a significant impact even in the most dire cases. Sometimes, getting very ill, as awful as that is for the patient and family, can open the door to a new path of recovery.

1/28/16

Obesity and Eating Disorder Treatment in Medicine

Obesity treatment is an increasingly important field in public health. Many posts in this blog have explained the intersection between obesity and eating disorder treatment although there is little practical collaboration. The fields have very little overlap in research and clinical work despite a significant need for the two to work together. 

The obesity branch of medicine focuses on understanding overall metabolism through a biological framework. Research elucidates chemical pathways in order to produce medications to control weight. Patient education revolves around nutrition and lifestyle choices. Bariatric surgery is always an option when the general medical approach is ineffective. 

Eating disorder treatment does not focus on biology and medications since that treatment is minimally effective at best for recovery. Instead the clinical approach uses a psychological model to approach meal plans and food support to normalize eating. Psychotherapy helps identify emotional triggers that lead to eating disorder symptoms and allows patients to more easily adhere to normalized eating and cope with stresses in different ways. 

It's typical that these two disparate branches of medicine do not see how complementary the models could be. Chronic eating disorders cause significant damage to metabolism. Obesity research and medications can often help normalize metabolism faster, something critical for patents early in recovery after a long illness. Similarly, many patients seeking help for obesity need to better understand the interaction between food and their emotional states to have better outcomes in an attempt to regain health. 


It behooves both clinical worlds to see each other as collaborators to help the growing population who suffer from these illnesses. An increasingly coordinated understanding of the complex effect of abundance of foods and the onslaught of high fat, high sugar and processed foods in our diet will increase the overall health of our population.

1/21/16

Subtypes of Binge Eating Disorder and Treatment

Binge Eating Disorder was the first eating disorder considered a true illness by the psychiatric community besides anorexia and bulimia. It is still underdiagnosed and often unrecognized although the approval of Vyvanse for treatment last year, if questionable, brought needed attention to the disease. 

The classification of BED is still limited due to the lack of thorough research, but the subtypes are varied and the treatment, although similar in ways to other eating disorders, has significant differences. 

The type of symptoms can be very different for patients. Some people binge on large quantities of food very quickly while others will feel the urge to eat normal or large meals, often many times per day, which sometimes is called compulsive overeating. Still other people describe an addictive response to certain foods, usually bread or sugar. Without these foods, their eating is very normal, but these foods can trigger an addictive response that leads to days or weeks of overeating just those addictive foods. 

Most clinical centers do not distinguish BED as a separate illness and instead treat these patients with the same methods used for people with anorexia and bulimia, with limited success. Often people with binge eating seek medical help instead and are led to the same treatment used for obesity. Frustrated with these options, many patients seek help outside the clinical establishment through other programs such as Overeaters Anonymous. 

What people with binge eating disorder need is individualized treatment for their specific symptoms. Creating a legitimate diagnosis and approving a medication for BED brought attention to the illness that hopefully will increase clinical research into new treatment approaches. 

Of the three subtypes mentioned above, people with sizable binges will get the most success from current therapy protocols. The binges are similar to those of bulimia and the treatment tends to be just as effective. 

People with compulsive overeating will get benefit from the standard treatment for bulimia as well but with more limited success. The emotional component of that form of eating is much stronger than for most eating disorders and demands more thorough therapy for those triggers. The symptoms tend to start later than in most eating disorders and have a strong emotional and behavioral drive. Disentangling that drive needs a combination of focus on food and normalizing eating with work on the emotional triggers. 

The addictive subtype of binge eating disorder is the hardest to treat. Often these symptoms start at a young age and the symptoms lead to a chemical high that is very habit forming. The cravings for another high can be overwhelmingly strong. Twelve step programs can be very helpful and mindfulness around the cravings also helps with treatment. The concepts of sobriety and sponsorship used in these programs are also helpful. Not infrequently, medications can be extremely effective in treating the addictive component as well. 


The incidence of binge eating disorder continues to grow and the clinical community needs to learn more about the illness and its subtypes in order to develop successful diagnosis and treatment.

1/14/16

The Gastrointestinal Symptoms of Eating Disorders

Eating disorders are medical as well as psychiatric diseases. The disordered thoughts are the driving forces of the illness, but thorough clinical care during recovery also means diagnosing and treating the physical problems as well. 

However, many physicians know little about the common medical problems associated with eating disorders. Chronic starvation and malnutrition are rarely seen in other situations in the first world. The medical effects of regular vomiting are also not conditions typically treated by physicians. 

The result is that most doctors attempt to fit patients with eating disorders into incorrect categories because the conditions are largely unfamiliar, leading to routine misdiagnosis and incorrect treatment. 

The most common specialty these patients see is the gastroenterologist. The stomach and intestines are directly affected by eating disorder symptoms and cause a plethora of problems most of which are reversible with recovery. 

Patients who primarily restrict food experience nausea, bloating and constipation. The best way to understand what happens to the GI system for these people 
 is to envision their gut as a muscle. As they eat less food, they use the muscle less frequently and the muscle weakens and begins to atrophy. The entire digestive system then works so slowly when given food that it leads to the symptoms above, indicative of slowed digestion.

If the symptoms persist for years, then the diagnosis changes from slowed digestion to more chronic problems: gastroparesis (very slowed digestion in the stomach) and colonic inertia (very slowed intestinal function). These diagnoses can be slow to abate if present for many years. 

Patients who purge or use laxatives regularly have a different set of GI symptoms, including stomach irritation, pain and bleeding and chronic constipation or diarrhea. The compensatory behaviors of their eating disorders cause constant trauma to their body which can lead to long lasting damage.

Chronic vomiting teaches the GI system to expect not to digest food but instead to expel it. The barrier between the stomach and esophagus loosens, allowing more acid to rebound into the esophagus and mouth called reflux. The acid production becomes irregular often causing irritation or an ulcer. Digestion is impaired from the constant trauma and the stomach has trouble functioning normally.

Laxative use causes similar trauma to the intestines which lose their ability to move food through the body and leads to chronic constipation. Excessive laxative use impairs the intestines enough that all food passes through undigested as diarrhea. The laxatives cause consistent fluid loss through diarrhea and forces a change in the mechanism the body uses to remaining hydrated often causing chronic fluid retention. Any break in laxative use can cause significant constipation. Last, laxatives are addictive and sudden cessation of use itself can be dangerous. So anyone stopping laxatives needs medical help to do so safely. 


It's important to recognize that these symptoms are not a reason to blame the patient. No one asks to get sick with an eating disorder. These GI symptoms and illnesses are real problems that need attention, diagnosis and treatment. Getting all the medical help needed is an important part of recovery.

1/7/16

Trauma and Eating Disorders

Trauma is a common cause of eating disorders, around 10-15%, but represents an important subset because the treatment needs are very different. 

Starvation for those with a traumatic history often has a very specific and personal meaning commonly related to both denying oneself care and comfort and serving as a way to re-experience the pain of the past.  

Starvation has long been used as a weapon, and that experience is connected to the role of an eating disorder in coping with trauma.  Individuals turn to hunger strikes as a public demonstration of opinion or outrage. Captors starve prisoners to yield information. Prisoners starve in protest. Starving an entire population can force people into submission. The populations of many countries starve while others have enormous excess food, which is not a direct expression as much as a sign of the meaning of food in disparate parts of the world. 

As starvation has taken on many meanings in the world, from the individual to the collective, it's not surprising that eating disorders have become an increasingly common syndrome associated with trauma. 

Eating disorder symptoms caused by trauma tend to be more chaotic and driven by a strong urgency. These people experience daily life happening in ways they cannot manage or alter. Much like the actual experience of trauma, daily events feel like they unfold on their own. These people never felt agency in their lives and still don't. Although many eating disorder symptoms feel as if they happen on their own, most people with eating disorders feel that there is always a part of themselves not swallowed by the illness. People with a history of trauma feel completely consumed by the eating disorder largely to escape the dread associated with the traumatic memories. 

Safety is the primary focus of treatment for people with trauma. They need to believe therapy is a safe place to start to address the feelings and experiences associated with their past and memories. At the same time, the person needs to be safe enough in their eating disorder not to be in medical danger. Often the line between medical safety and emotional safety can be tricky and confusing. 

The treatment needs to focus on trauma therapy from the start. That pain cannot be avoided in order to look at the eating disorder. They both need to be faced simultaneously. Since starvation can affect physical and emotional stability, the treatment is difficult and needs to constantly monitor all aspects of the person's well-being. However, any other approach for help will backfire. 


The most important aspect for the treatment is to combine that safety with compassion. The suffering both through trauma and through the eating disorder is great. Health and recovery are real possibilities, and therapy needs to start with that hope and reinforce it at every turn.

12/23/15

Can Bariatric Surgery Cause an Eating Disorder?

Repeated experiences seeing post-Bariatric surgery patients are perplexing and disturbing to the clinician who treats people with eating disorders. Obesity is clearly a significant health issue in large parts of the world; however, permanently altering someone's gastrointestinal anatomy to make possible longterm starvation is a destructive and counterproductive solution. 

The grand experiment of culturally sanctioned starvation has caused multiple chronic medical problems, number one on the list being eating disorders. The result of idealizing the extremely thin has been to encourage and blindly support constant dieting and starving. 

We have learned that people have a varied but ingrained and largely genetic response to chronic starvation. The most common response is overarching hunger that usually triggers one form of eating disorder symptoms or another. 

Bariatric surgery often causes a form of binge eating. Most people can starve for 6-9 months and lose a significant of weight before the starvation response takes over and the uncontrollable urge to eat dominates one's thoughts and actions, thereby leading to binging. 

The solution, as with all eating disorders, is to start by normalizing a meal plan. Consistent nutrition signals the body and mind that the famine is over so normal body function can resume. Doing so will gradually let the starvation response subside. 

What's particularly concerning is the medical community's reaction to these cases. Uneducated in eating disorders, most doctors are perplexed by these symptoms. Bariatric surgeons continue to encourage starvation and weight loss, while the Bariatric nutritionists do not consider changing their recommendations for prolonged malnutrition. Endocrinologists encourage medications to treat the increased hunger. No one considers the effect of chronic starvation, largely because thinness is of primary importance. 


The Bariatric community needs to team up more closely with eating disorder clinicians in order to better understand the repercussions of these surgeries. Curing obesity by causing an eating disorder is certainly not a viable means of treatment.

12/17/15

Can People with Eating Disorders be "Treatment Dependent"?

I heard a new term in the treatment of people with eating disorders this week: treatment-dependent patients. I was flabbergasted by the judgment and blame associated with this label, especially since it came from a program well versed in the need for kindness and compassion. 

The overt message appeared to be that patients should not be dependent on their treatment to get well while the implied message is that chronicity of an eating disorder is the patient's fault. 

For those who read my blog, it's clear that dependence on treatment is a necessary part of recovery. The eating disorder serves as a constant companion, comfort and salve for all the events of daily life. Weaning oneself from such a critical part of life demands a drastic shift in lifestyle. Depending on treatment can be a bridge towards learning how to depend on close relationships in daily life while learning how to eat normally again. That dependence makes the eating disorder less necessary over time. The relationship serves as a jumping off point for independence, not a reason to remain ill. 

The chronicity of an eating disorder is not the failure of the patient. The implied message is that the person just needs to try harder or to learn to stand on her own two feet. Anyone knowledgable in eating disorder treatment knows this message only sends someone to relapse because it reinforces self-criticism and self-blame, the cornerstones of the eating disorder.

The eating disorder thoughts and behaviors become so ingrained and automatic that only sustained support to change these patterns over time will have an impact. Urging someone to just figure it out implies a lack of ability on the treatment providers to manage the illness. 
This is certainly not the first time I have heard clinicians blame the patient for her illness. Usually inexperienced therapists will state uneducated opinions which only show a lack of understanding of the nuances of eating disorders. That's not surprising since it is hard to find thorough training for treatment of these illnesses. 


However, the term treatment-dependence comes from an established and esteemed organization. When patients are blamed for their illnesses, it's time for the treatment providers to delve into their own motives to be sure they have the clarity needed for this type of work.