Eating Disorders and Suicidal Thoughts

Eating disorders are relentless mental illnesses. The struggle and suffering that stem from both the physical starvation and the mental torture are exhausting. People who have not had much treatment and don't know what the recovery process looks like can become very hopeless. The severity of the despair can sometimes lead to suicidal thoughts and even suicide. 

Three components of eating disorders increase the risk of hopelessness and suicidal thoughts for people with eating disorders. 

The first risk factor is secrecy. The eating disorder thought process involves a constant need for secrecy. Only in private can someone fully engage in the eating disorder. This urge often leads to lying and hiding in order to create time and space for the illness and the behaviors. Since most people with eating disorders are straightforward and direct, the secrecy creates a sense of hopelessness and despair based on behaviors anathema to their true selves. The idea that the illness leads them to behavior so out of character opens the door to feeling hopeless that life can ever change or be different. 

A deep sense of shame, something I have explored many times in his blog, creates a thought process of feeling intensely negative thoughts about oneself. Years of reinforcing behaviors and thoughts can create a hopeless feeling of being trapped in this shame with no way out. Shame is often a feeling that inundates all other feelings about oneself. Buried in shame, someone with an eating disorder typically feels very hopeless. 

Most people will seek treatment at some point, but the kind of therapy they receive makes a difference as to whether this cycle of hopelessness continues unhindered or comes into question. Seeing a clinician with a profound knowledge of eating disorder thoughts quickly makes a sufferer imagine that the secrecy, shame and hopelessness may very well be unfounded. It makes the idea and process of recovery realistic. On the other hand, a session with a less experienced clinician can only confirm these fears thereby strengthening the hopelessness and suicidal thoughts. 

Suicidality is a common and very serious component of chronic eating disorders. It is the absolute responsibility of the treatment community to provide solace and guidance to find a way out of this desperation towards treatment and recovery.


When to Choose Residential Treatment

One difficult decision in eating disorder treatment is whether or not to go to residential treatment. The factors around patient safety, the course of recovery and the anxiety of the clinician all make the process tricky. 

The number one reason for someone to go into treatment is patient safety. If an eating disorder has led to medical instability, organ damage or significant functional impairment, then the recommendation for inpatient treatment is clearcut. More often than not, any treatment team can come to this conclusion fairly easily. 

Many situations do not present such clear alternatives. When a patient has been in treatment for a period of time without making much progress, the choice of a higher level of care, clinical jargon to mean day treatment or residential treatment, becomes an option on the table. Frequently, the suggestion for more care comes from frustration of the treatment team around the lack of progress rather than a clear indication or need for residential treatment. The idea is that more treatment will kickstart the recovery process and lead to more rapid improvement. However, there is little evidence that this clinical step is successful. 

Another reason clinicians recommend inpatient treatment is the discomfort of the team with the level of a patient's symptom use. Even if that person is functioning and is medically stable, many clinicians struggle with the anxiety of seeing a chronically ill patient. Recommending residential treatment may be a salve to the concern of the clinician, but the key question is whether or not it is beneficial to the patient. 

Instead there are a few questions that would behoove a clinician or team before suggesting inpatient treatment. First, if the patient is at significant medical risk or is minimally functioning, then residential treatment is an option. If someone has not had good experiences with inpatient treatment before, then it is crucial to have specific reasons to consider this option and why it would be different. All clinicians and teams must assess their own fears and anxieties before suggesting inpatient treatment. Last, a team must have clear and reasonable goals for this step in recovery. Unrealistic expectations or even imagining a panacea that sets up the patient for failure are ways to absolve oneself of responsibility, not a benefit to the patient. 

Inpatient treatment is an option for the process of recovery. It must be considered carefully and clearly. The expense in time and energy is significant. This step should never be considered without clear and reasonable intention and assumption of the gravity of the decision.


Facing Eating Disorder Delusions, Part II

Internalizing the idea that the eating disorder creates a false world of beliefs is a significant step in recovery. But delusions, by definition, feel like reality to the person who has them, so questioning that reality is a monumental step forward. 

By and large, people with eating disorder delusions live in a world founded on these beliefs. If these thoughts come under question, one's entire belief system and even the structure of daily life has to be reevaluated. 

It is rare that adults are forced to reassess the way they live their lives. Catastrophic events can force adults to do so, like war or natural disaster or financial ruin. Social changes such as divorce or the loss of a loved one can also make adults rethink their lives. But most adults live in a world of set values and mores. They don't need to question the fundamental rules of the world they live in. 

There comes a point in recovery when people are capable of identifying and questioning the delusions of their eating disorder. They may not always want to question them because it is painful to recognize the lies that have governed their lives; however, they also know that living according to these lies is too destructive to continue. 

For them, facing the delusions is akin to completely reassessing their world and the foundational beliefs of their lives.  This is often the most important step in treatment. It enables people to see a life that is fully recovered and much more full.

As scary as this new world looks, reminding the person that disavowing these long held, false beliefs will create a truer and complete life will enable the person to take large steps in recovery. Above all, emotional support and compassion are the key to facing the delusions and entering a new world.


Eating Disorder/Healthy Self Dialogues

There are many ways to approach the delusional thoughts but only one appears to be consistently effective. In order to use this method, the person already needs to understand that the eating disorder thoughts are delusional and also at least acknowledge that more logical thoughts exist and would encourage recovery. With that foundation, treatment can move forward. 

The core piece of this step in therapy is to create an internal dialogue between the eating disorder thoughts and the healthy thoughts. The ed thoughts have usually felt completely true and also secret for a long time. Exposing them can be emotionally challenging and even scary to admit openly. The healthy thoughts often feel forced and unsure. It takes time for these thoughts to start to seem true and supplant the eating disorder thoughts. 

It is also important that both sets of thoughts come from the person struggling with the eating disorder. It's counterproductive for the healthy thoughts to come from someone else. The purpose of the exercise is to practice and express the healthy thoughts and learn to associate oneself with a new way of thinking. 

An example of the dialogue can start with the idea that one shouldn't have lunch. 

Ed: You don't need lunch today. You're not hungry. 

HS: Food is a part of recovery. Hunger is not the issue. Eating to live is the issue. Following the meal plan is crucial to get well. 

Ed: You're already fat. You don't need food. 

HS: Without food you just end up getting sicker and unable to live your life. 

Ed: But you want to be skinny. That's most important. 

HS: You've done that before. Then you end up in treatment and unable to make friends or do anything. Life is much more than starving. 

Typically the dialogue leads to the conclusion that the eating disorder thoughts only want the person to live for the illness itself. There is no purpose beyond that and it leaves no meaningful life in its wake. 

Although this is a hard part of recovery, it is crucial to help combat longstanding delusional beliefs. Making these changes and doing the consistent work is a big part of the reason people can fully recover.


Facing Eating Disorder Delusions, Part I

Typically delusional thoughts are fixed beliefs about the world that someone is convinced are true but that are clearly false. More often than not, these beliefs are so prominent and so all consuming that they significantly disrupt the person's life and relationships. 

Sometimes the delusions can be circumscribed, for instance focused solely on one person or one event happening in the world. In these circumstances, the delusions only come to light when the specific target is discussed. 

Delusions in an eating disorder are both circumscribed and also internal. The fake beliefs about food and weight only pertain to that person and not others. In addition, the thoughts are shrouded in secrecy and rarely come to light. Unlike almost all other delusions, they only are revealed when questions probe enough to elicit the beliefs. 

Yet these delusions are so powerful that they affect most decisions every single day and profoundly limit how someone lives their life. 

Eating disorder delusions come in two similar patterns. First they can revolve around severe limitations of foods that one can eat or the amount one is allowed to eat. Breaking these laws around food actually feels like doing something absolutely horrific, something illegal that deserves punishment.

The delusions can also revolve around a belief that the person either has never been sick with an eating disorder or has never been very sick despite clear evidence that proves otherwise. Some people with clear organ damage or even at risk of dying still believe they are well. 

It's important to recognize that these are thoughts someone with an eating disorder absolutely believes are true. They are not just passing thoughts. This is often what makes understanding these illnesses so hard. 

Questioning delusions is very difficult. Directly confronting them typically fails immediately and brings any trust in a relationship into question. The way to challenge these fixed thoughts is to essentially build a case against them.

By amassing evidence that shows how these delusions are false, one can begin to bring to light the lack of data to prove these thoughts are true. Even with overwhelming evidence, it can continue to be hard to escape a delusion. It often takes months of questioning the thoughts to weaken them in time.

Gradually, the most important step is to help the person herself begin to question the delusions directly. I'll discuss that more in the next post.


Delusional Eating Disorder Thoughts

The large majority of people with eating disorders seem fairly well and functional on the surface. Although the physical and psychological effects of the illness are rampant, most people can engage in conversation, hold down a job or go to school and maintain stable enough connections in the world. 

The juxtaposition of someone who appears well but actually suffers from a serious disease is confusing for many people. It contributes to the difficulty many have with believing an eating disorder is a life threatening illness. 

To those unaware of the nature of eating disorders, recovery could easily just mean starting to eat normally, as if the symptoms are a choice. That's the primary misunderstanding which explains why it's so hard for laypeople to comprehend the nature of these illnesses. If getting well were a choice, eating disorders wouldn't exist in the first place. 

What lies underneath the seemingly normal facade is a thought process that drives the eating disorder. These thoughts make it a powerful and destructive illness. Distinguishing between clearly delusional eating disorder thoughts and healthy thoughts is extremely confusing for people in recovery. The process of recovery is largely about learning to identify and ignore the eating disorder thoughts. However, disregarding thoughts that have structured daily life for years takes time. 

For the purpose of this blog, I will call these thoughts delusional. Clinically, a delusion is a fixed false belief. In the case of eating disorders, a common delusion is, for example, "I can't be thin enough" or "this crash diet will finally stop the binging" or "I'm really fine even though I feel weak and dizzy" or "I'll just use laxatives one more time." 

The next few posts will explain in more detail what the delusional component of an eating disorder entails and the process of learning how to ignore them and move ahead in recovery.


The Role of Medications to Treat Binge Eating Disorder

Unlike people with other eating disorders, those with Binge Eating Disorder often contact me solely to talk about medications. Sometimes they want to meet to discuss medication options or even, if they live outside of New York, ask to speak on the phone for a few minutes. 

There is a widely accepted view that medications are unlikely to be a significant part of treatment for other eating disorders, but the idea that medications can temper, if not cure, binge eating is pervasive. 

From a clinician's point of view, treating binge eating is similar to treating other eating disorders. The focus on a combination of normalizing eating patterns while zeroing in on the emotional and psychological manifestations of the illness is paramount. There is no evidence that medications help binge eating any more than other eating disorders. 

Seemingly, the media and lay knowledge of eating disorders categorize binge eating as something different. It represents, in our current culture, a flaw or a sign of weakness. As medication has become more central to psychiatric treatment, it is natural to assume there must be medication to fix this core craving or, as some falsely describe it, lack of willpower. 

The reality is that binge eating is one of a variety of biological and psychological adaptations to chronic undereating. We are all programmed to respond to prolonged starvation, i.e. dieting, in different ways. For some people, the starvation mechanism cascades into compulsive starvation and leads to anorexia. For some, the diet ends abruptly and leads to normal eating. For others, it triggers binge eating which can lead to bulimia, binge eating disorder or a variety of compensatory mechanisms to deal with overeating. 

Ultimately, the course of treatment needs to be the same. And a key component of treating binge eating disorder is to take the shame away from binge eating and follow a comprehensive treatment plan rather than a pharmacological magic fix. It's not a flaw but part of an illness.