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.


Weight Bias and Biology

The idea that our bodies know how to function also applies to people who are overweight. They experience overwhelming pressure from society, friends and family to lose weight with the often unspoken message that their weight is a sign of their own weakness and slothfulness. 

The drive for thinness and dieting is usually even more pronounced for those who are overweight. The diet industry plies the public with unsubstantiated miracle fixes for weight loss and happily reaps significant profit on the misery of others. Meanwhile, the government, medical establishment and even close family and friends all support these endeavors as signs of self-care or even self-love. The promulgation of an endless search for the pot of gold at the end of the rainbow all to satisfy the misguided idea that weight is both a manipulatable data point and a sign of virtue is abhorrent. 

The accepted messages about food and weight can easily become personal rebukes of those who are overweight and even open the door to widespread, accepted prejudice. If the person is misled into conflating self-worth and weight, they are susceptible to all types of bias and mistreatment. 

Meanwhile, the human body functions solely on biological terms, irrespective of the current societal norms around weight. As I have written extensively in this blog, weight is not commensurate with health, and there are ample data to prove this point which is summarily ignored by the powerful diet industry. 

All the noise around weight and virtue drowns out the facts. Our bodies know how to manage hunger and food. Given the necessary diet, humans can live and thrive. Weight is but one data point of many that the body works to keep within a range commensurate with health, and the range is largely predetermined by our genetics. Our body size and shape are part of our inherent nature, not signs of personal virtue. 

First and foremost, food and weight are not indicators of our worth as a person. The message of biology trumps all other specious explanations of health and weight. This message needs to be trumpeted and spread to counter the overarching and destructive falsehoods spread by the diet, food and exercise industries.


The Central Myth of Eating Disorder Thoughts

A refrain of eating disorder treatment is your body knows how to function. Give it enough food and it will take care of itself. The saying begins to be trite the more often one hears it, but the challenge is to recognize how profound it really is. Ultimately, believing this simple message can help someone with an eating disorder discount the majority of what any eating disorder thoughts deem as true. 

Food is a biological necessity for life, as crucial as oxygen, water and sleep. However, of these absolutes, only food is so mutable to allow for someone to attempt to constantly manipulate and adapt their food choices. 

The confusing messages society consistently supports is that one's diet is something to work on and perfect. There's a widely accepted belief that choosing food wisely, if not perfectly, will transform weight and health, if not the course of life itself. Meanwhile, the body will digest, absorb and utilize the energy from food in its own way no matter what one eats. Weight is a data point the body manages for health and wellbeing. And the vagaries of daily life are not related at all to what one decides to have for lunch. 

The best argument to use against exaggerated, if not magical, thoughts about food and diet is that food is a basic necessity of life. Biology dictates what our body needs and how it functions. Our life course and decisions are what we can all try to affect and move through. Expecting food choice to fix life's problems means ignoring one's realities. And our lives need as much attention we can give them.


The Separation of Meaning and Weight

People engaged in recovery from an eating disorder comment on how personal and how philosophical the process is. They marvel at their internal growth and maturation and at how their view of themselves and the world has transformed. 

In the same breath, they often ask why eating disorder recovery needs to be this way. If eating disorders are largely destructive behavioral patterns, why can't behavioral treatment lead to health and wellness?

The answer lies in the fact that ingrained food behaviors tap into our basic human drive for survival. Accordingly, deeply rooted food behaviors function within the oldest and least conscious parts of our brains, parts we share with much more primitive living beings. And so once food behaviors are fixed, changing them becomes overwhelmingly difficult. The patterns exist in the least accessible parts of our psyche. 

As I wrote in the last post, once the survival instinct transitions to diet and weight management, it starts to feel as if maintaining a certain weight is as urgent as our survival. Once that instinct is triggered, changing the association is very challenging. 

The key to creating a meaningful life, one not dominates by the endless search for the perfect diet, exercise plan and weight, lies in the most successful eating disorder treatments. Although the severity of the medical and psychological risk is much greater for people who suffer from these illnesses, the methods used to change profoundly ingrained food behaviors are relevant for both. 

The medical or purely practical approach to treating people with eating disorders is hardly ever successful. Short-term improvement in health belies the course of the eating disorder. Inevitably, the eating disorder thought process hardens when someone is forced to make behavior changes. It may appease clinicians to blame the person for her illness in this situation, but the clear problem remains in the treatment decisions. 

Treatment directed towards a fuller recovery combines refeeding and improved health with a consistent message of creating a meaningful life. Using our conscious brains to introduce and reinforce the need for useful activities, important relationships and intrinsic personal value creates a foundation to combat the eating disorder thoughts.

The psychological process of recovery involves replacing the old eating disorder thoughts about food and weight with a  new philosophy focused on meaning and relationships. As the new philosophy strengthens, the old eating behaviors lose steam and normal food patterns dominate. 

Applied to the general world focused on weight and appearance, the message that dieting doesn't work is too practical. There is no personally meaningful voice or system to replace the incredibly powerful diet, food and exercise industries. It's not a surprise that even those fed up with living their life for weight loss turn to Bariatric surgery for relief rather than a compassionate and kind approach the identity and life. 

The messages competing with the seemingly perfect life of diet and exercise need to find their way into our daily awareness to be effective.


Thinness and the Survival Instinct

The backlash to the dieting culture has been relatively quiet and even meek. There is plenty of evidence that diets don't work and that health is not related to size. But these realistic voices don't make a dent. Slavish focus on weight, food and exercise dominates the mindset of our culture. And at this point, the void that would emerge from eliminating the thin bias is hard to overestimate. We are trained to believe that we need the obsession with weight. Without it, apparently, we would all be lost. 

Believe it or not, a large part of our consciousness centers on survival. This basic instinct has utilized our higher order level of thinking for millennia to outlast and outperform all other species. We tend to think our superior intelligence and problem-solving skills make us evolved beings, but the true element of our station in the world is our ability to survive. Whether it is related to making fire to cook food, ingenious methods to protect ourselves from predators or various means to combat bacteria such as purifying water or antibiotics, our successes rely heavily on the combination of our sophisticated brainpower and our most primitive instincts. 

But now this success has caught up with us. If life for many fortunate people is fairly stable without any imminent risk to health or survival, where can we apply these powerful instincts? Being human means the need to survive remains very present and very strong. Perhaps there's no immediate risk, but this fundamental part of our biological makeup remains intact. 

The combination of strong cultural pressure and social science applied to marketing has brought these instincts full circle. Our need for thinness has changed from a societal norm into a what feels like a biological necessity. Too many people cannot function unless they weigh a certain number or fit into a certain size clothing. The urgency to be thin is increasingly conflated with the survival instinct. For many, life cannot go on normally without thinness. 

Meanwhile, various industries use the vast knowledge about food, metabolism and human suggestibility to create foods, weight loss plans and exercise regimens that encourage a lifestyle largely centered around food and weight. There is a sense of inevitability and virtuosity to the ascetic life focused on diet and exercise. In the end, this ultimate goal of thinness creates nothing more than a small, meaningless life. 

Since we cannot eliminate our survival instinct, we as humans need to find a place to apply it. Allowing industry and culture to shift survival to something as banal as weight isn't creating meaningful lives. Recovery from eating disorders focuses on authenticity and deepening personal relationships as the antidotes. Is this lesson one that can work in a larger context? I'll talk about this more in the next post.


Can Dieting Create Meaning in our Lives

Diet and weight have come to define purpose and success in our lives. The clear data that prove the ineffectiveness of diets and various weight loss regimens never appear to sway the underlying premise of our collective goal. The fundamental concern isn't medical. It's psychological. 

We live in a world where only thinness is normative. The most widely accepted weight scale, BMI, skews heavily towards the lower end of the spectrum and does not take into account the variety of body shapes and makeup. Weight bias pervades all aspects of our culture from media to fashion, business to healthcare. Professionals of all stripes adhere closely to the expectation of thinness. Most people are not at all aware of how weight bias colors their perception every day. 

New movements to counter this insidious fat phobia are more and more prevalent. Body positivity espouses the concept of accepting and appreciating the body you have regardless of size. Health at Every Size, a successful government-sponsored program, has been shown to improve overall health significantly without focusing on weight loss. Yet successful alternatives to weight bias do not affect the central psychological driver for our collective belief. 

Daily life tends to isolate us in our small worlds and to limit our ability to see the overall benefits of our existence. More often than not, those lucky enough to be free of illness or immediate threats to our well-being struggle to find meaning or urgency in our lives. 

The human yearning for purpose has persisted over centuries, and we all struggle to latch onto a tangible meaning for our lives, especially in the modern post-industrial, digital age. One clear salve for the masses is dieting and weight. The daily struggle gives direction for each day. The success or failure of following a diet or losing weight structures an otherwise aimless life. 

So the purpose of dieting is only purportedly to lose weight. The meaning runs deeper and the need for daily structure is even more important than the outcome. That's why people diet or focus on food and weight their entire lives. With this background, what comes next? I'll continue in the next post.


The Magical World of the Perfect Diet

With all this knowledge about biology and weight, it would seem obvious that these facts would change our behavior. However, this knowledge fades into the background amid unsubstantiated, clearly untrue dieting advice. 

It's hard to conceive of why the public would choose a clearly impossible goal of weight loss over a proven path of following the body's own internal signals. Clearly the scientific facts could provide some sense of peace. Yet the drive for thinness remains paramount for the modern adult. 

The meaning of thinness surpasses all success in our culture. Without achieving it, any other achievements are discounted. Even without other meaning in life, thinness itself counts as true success. 

The cultural zeitgeist has elevated thinness to a true measure of a person's value. In these circumstances, scientific knowledge can't be fully accepted. The fantasy that permanent weight loss brought by the perfect combination of diet and exercise must exist, according to this precept.

To conceive of a world without that panacea is analogous to a child believing in a world without Santa Claus. 

In fact, the deeply held belief system around weight leads our population into dangerous territory all the time, heedless of the risk. Children taken to weight loss camps at age eight. Doctors chastising patients about weight without any facts to substantiate their medical recommendations. Communities of adolescents teaching each other how to purge in the school bathroom. Hoards of adults willingly allowing doctors to surgically destroy their gastrointestinal systems. 

As the repercussions grow for various weight loss regimens, the risk to our community also grows. The long term questions about our state of mind and our collective life purpose become clearer. How can we all wake up from this nightmare and define a successful and useful life outside of food and weight? Facts may be necessary but clearly aren't sufficient. The next few posts will address this concern.


The Hard Facts about Weight Loss and Biology

Nothing about homeostasis and weight, as discussed in the last post, is new information. There is more research in recent years to provide evidence for this biological function, but it's not news that the body monitors and manages weight for overall health. 

However, the constant messages from the diet, exercise and food industries completely ignore this reality. These business interests dominate the information available about food and weight and have convinced people, medical practitioners and even government organizations that weight is within our control and a necessary part of overall health. 

Since the cultural norm in recent generations is thinness, it's not hard to convince the public that being thin is preferable. Using weight as a measure for health, longevity and well-being is an easy sell for a population already inclined to believe that thinness is equated with personal value and self-worth. 

In addition, these industries all give clear instructions for attaining said goals. Each new diet regimen purports to be the magic fix for weight loss. Every exercise plan is guaranteed to lead to permanent changes in one's body. Bariatric surgery programs or weight loss centers provide hope for those who fear being destined to their current weight forever. And the food industry rolls out one new food product after another meant to insure health and weight loss. 

What information does the knowledge about homeostasis provide? Can it compare with the prescriptive advice that comes from industry and the media?

Biology only promises that if you eat regularly through the day with typical size portions for meals and snacks and if you follow your hunger and fullness cues, then your body will fall within a reasonable weight range of about 10-15% of your current weight. And if you try to go out of that range, your body will resist weight loss but may gradually allow weight gain. 

Given the choice between the messages of industry and biology, it's clear why the various industries, with their extensive public relations, are much more successful. 

Yet homeostasis is the fundamental basis for how the body manages weight. And all the other messaging about food and weight are patently incorrect. 

So the goal really has to be to learn how to work within the rules that make our bodies function. Philosophies such as intuitive eating or Health at Every Size explain at length what it means to learn how to pay attention to our own internal cues. These approaches aren't easy in today's world, but they are realistic.

Our common goal has to be learning to listen to how our bodies work. Fighting those instincts only leads to misery and endless hours spent on fruitlessly managing an unmanageable task.


Homeostasis: Health and Balance in our Bodies

Homeostasis is a cornerstone of human health. It represents the concept of balance from a biological standpoint. All organs function well when the body can maintain balance and stability of all of its variables. This includes blood levels of electrolytes such as sodium and potassium, ample amount of vitamins and minerals and hydration levels both in the blood and in our cells. The body doesn't require an exact level of these variables but just to be within a normal range. As long as the values remain within that range, our bodies thrive. When the levels go out of range, our bodies will immediately adapt to try to right the system. 

Homeostasis also includes weight. 

Our bodies have intricate signals to monitor weight, nutrition and fat levels. They are a variety of hormones, many of which we still have not even identified, which travel in our bloodstream and alert our organs and brain about our current weight, nutritional status and fat stores. These signals can affect many organ systems and body functions including appetite regulation, metabolism, fat storage versus fat usage and more or less efficient digestion.

Over the course of human existence, the human body has honed these signals for survival. The ultimate goal is to thrive as a species. That means that the paramount objective is to maintain the biological state commensurate with health and longevity. 

It does not mean lose weight or maintain a lower weight, despite our own personal desires. In the end, homeostasis determines our weight. 

Chronic dieting and obsession with thinness challenge our basic biological system. Although many social forces have led to our competing wishes between thinness through dieting or exercise and the desire for ample supplies of processed foods provided by a powerful food industry, our biology trumps all of these pressures. 

The end result is twofold. First we now have a population that has gradually increased in weight for many reasons written about extensively. Second the diet industry has influenced widespread food restriction which triggers a biophysical response to regain weight and stabilize physical health. Ultimately, biological imperative will be victorious over even our best laid plans. Maintaining a weight necessary for survival matters; our desire for thinness doesn't. 

If we accept the biological reality of homeostasis, what direction do we have for eating disorders and disordered eating treatment? I will address this in the next post. 


The Three Biggest Myths about Weight

Several myths about weight drive an enormous amount of mental anguish in our society. They support the diet, food and exercise industries. They increase the risk of developing an eating disorder. And they cause an enormous amount of suffering and misery. 

Here is a list of the top three with some explanation of the reality. 

1 Diets work but just demand enough willpower. 

Research study after research study has proven, without a doubt, that diets don't work. In fact, extensive research proves that diets inevitably lead to long term weight gain. Sustained periods of malnutrition push the body to release hormones that increase hunger over time and that lead to increased fat storage, all to avoid the risks from extended periods of famine. 

1 Weight loss leads to improved health. 

There is no correlation between weight and health. Despite clear evidence proving this point, doctors will often exhort patients to lose weight without recognizing they are only proponents of a powerful social bias. Health is attainable at any size. 

1 Exercise leads to weight loss. 

Exercise improves long term health significantly but leads to no sustained weight loss. The body compensates for exercise by needing more energy either through increased intake or extracting more calories from food, but long term research has shown no effective change in weight. 

These myths all stem from our collective need to feel like we can lose weight. Since weight has become the paramount sign of success in our culture, people are willing to accept any means of losing weight even if ample evidence proves otherwise. However, the myths don't jibe with basic knowledge of how the body works. The next post will address what actually affects our weight: balance or, in medical terms, homeostasis.


The Truth about Bariatric Surgery

A caveat to the recent posts about weight is the professional dilemma about Bariatric surgery. These weight loss centers, as they are called, have become a profit bonanza for hospitals. People bereft after years of unsuccessful dieting finally capitulate to the pressure for surgery from friends and doctors. It feels like a last resort, the final decision, and one couched in the misguided concept of improved health. The surgical centers are PR meccas able to reel in even the most ambivalent of patients. Once hooked, these people become true believers. 

They say they are done dieting and know they "haven't been able to use the tools of dieting successfully." The language of personal blame, well honed by diet gurus, allows doctors to recommend surgery and also not take personal responsibility when the surgery fails. 

We will all look back one day in shock and horror that the medical world sanctioned slicing off half or more of a person's stomach for weight loss. These surgeries may very well be the lobotomy of our time. When all data shows dieting to be not only ineffective but also harmful with clear proof it leads to long term weight gain, how can we stand by as the diet industry leads these people to a place of hopelessness and the medical establishment leads them into the operating room? The hypocrisy and craven desire for profit are astounding. 

The central issue is to wrest back the conversation from the extremely powerful diet, food and exercise industries which have completely monopolized the conversation. Sadly, the medical establishment has been led to the same conclusion and now acts as unwitting promoters for diets and surgery. 

The answers to this problem lie with medical education. Unless medical professionals understand the basic facts about food and weight, there will be no counterpoint to the marketplace powers which have capitalized on the fear of fat for enormous gain.


Weight, Part III

A friend recently diagnosed with a serious illness told me a story. She is working hard to maintain weight due to the potential for weight loss from her illness, and she heard someone bemoan her need to lose weight. This friend only wished her biggest problem was losing weight. 

It's a truism that poor health puts all mundane worries into perspective, but this story illustrates something more powerful in light of the recent posts on this blog. Worrying about weight is more than just a mundane concern. It represents something more profound about the empty struggles of modern day life. 

Ruminating about body and weight is now an acceptable way to vocalize and internalize daily problems. We all seem to have accepted that striving for thinness is necessary for overall success, and not achieving it can undermine any other, more meaningful accomplishments or realities. 

The problem with this concern is twofold. First, obsessing about weight and food triggers a deep part of our brains. Food obsession is linked with survival and basic needs of being a biological organism. Watching how food motivates pets is an easy way to prove how ingrained food behavior is in all animals. Once this brain circuit is triggered, it can become all encompassing and have a significant negative impact on daily life. 

The second issue is sanctioned starvation, something I have written about extensively in this blog. The diet industry juggernaut capitalizes on our collective desire for weight loss and paints dieting as a prudent way to live. However, the danger of dieting, always followed by compensatory overeating, is to actually precipitate disordered eating and eating disorders. 

If there is anything my ill friend pointed out, it's that our obsession with weight loss mirrors our loss of values. We must work hard to figure out what to prioritize in a world constantly vying for our attention. The important things in life need to reflect our own selves, not the demands of industry, vanity or culture. Weight obsession is a manufactured reality intended to capture our minds. Our deeper values can't be drowned out by this endless noise.


Weight, Part II

Weight is but one data point to assess medical progress during recovery from an eating disorder. When any person eats regularly for over a year, weight can still fluctuate quite a bit due to several factors such as fluid shifts, hormonal shifts, changing seasons and changes in daily routine. The body attempts to keep weight within a range, but that range is much wider than what many people can accept psychologically. 

Weight reflects part of the natural state of balance the body seeks in order to maintain stability called homeostasis. The human body works to stay in a range of weight to promote health but a specific weight is not important. 

People with eating disorders and many people focused on food and weight believe otherwise. They think they can control weight within a pound or even less, with the advent of scales that measure to the tenth of a pound. The psychological and emotional effort expended to maintain a specific number dominates many people's lives and completely takes over the mind of most people with an eating disorder. 

During eating disorder recovery, one's body often needs to switch into a healing mode which can have a significant effect on weight, albeit temporarily. For instance, many people become constipated as their gastrointestinal system heals which leads to bloating, fluid retention and increased weight. Metabolism can slow down to adjust to periods of starvation in all eating disorders which can result in a temporarily higher weight. Normalizing of fluid maintenance, how the body stores water, often leads to fluid retention and weight gain as well. 

These changes are short-term but cloud the use of weight as a marker of health. 

In addition to weight, there are many other ways to assess improvement in health. Regular food intake is the first and foremost sign of recovery. No matter the other factors, improvement in daily eating is a sign of health. People often experience increased energy, higher stamina, normalization in gastrointestinal function, ability to withstand temperature changes and improved circulation, to name a few. These markers of health take more time to follow and assess but give a much more thorough picture of health and recovery. 

The next post will take these thoughts about weight a step further. What are some reasons for our obsession with weight for people with eating disorders and for our society?


Weight, Part I

Medical management of eating disorders revolves around weight. Every day in residential treatment and at every appointment in outpatient care, getting on the scale is the focal moment for both patient and doctor. 

Weight fluctuations are central to many other illnesses and a good data point for progress or regression. But in treating people with eating disorders, doctors act as if weight is absolutely paramount. 

On the one hand, this seems reasonable. Eating disorder thought processes are almost exclusively about weight and body, so weight normalization appears to be key to recovery. Yet clinicians are often as focused or even more focused on the number on the scale than the person with the illness. Frequently, this dual obsession of patient and clinician sets up an unworkable battle. 

In all other illnesses, a clinician's focus is not on a data point but on health. Eating disorders cause many serious medical problems from anemia to kidney dysfunction to cardiovascular collapse. People routinely die from eating disorders. There are many physical signs and symptoms and clinical facts to address in addition to weight. 

In fact weight is often an elusive and confounding piece of information. Daily weights tend to reflect fluid shifts based on many factors. For instance, even a salty meal can lead to 2-3 pounds of extra fluid weight the next morning for anyone. Actual body mass rarely changes by even two pounds in a week, even for very underweight patients in residential treatment. 

So the question I often consider is why is the clinical world so focused on weight?

The first consideration is that abnormal weights upset clinicians, and weight normalization feels like healing a sick person. Most people with eating disorders whose weight has normalized actually suffer more because their eating disorder thoughts are so dominant. Treatment needs to address the psychological part of these illnesses as well, otherwise recovery is for the clinician's well-being, not the patient's. Focusing exclusively on weight reveals the unfortunate ignorance of many clinicians about recovery. 

The second factor is insurance companies. In order to avoid paying for care, insurance companies have limited the amount of care by assessing practical but very short-sighted data points. Weight is the primary focus. If a patient's weight is normal, then insurance companies limit access to care. Since people frequently change health insurance, these companies bank on providing a stopgap measure to save money. Long-term recovery is not a priority. 

If weight is not the central marker of successful recovery, how can clinicians and patients assess progress? I'll discuss that in the next post.


Clinicians with an Expertise in Eating Disorders

Most mental health clinicians learn how to treat the most common illnesses such as depression and anxiety. Certain psychiatric problems are not addressed in standard training, so finding specifically trained therapists and doctors is important. 

Eating disorders turn out to be among the most specialized example. 

The majority of training for psychiatrists, psychologists and social workers does not address how to treat people with eating disorders except in the most cursory ways. And eating disorders have the most medical complications of any mental illness, a fact which demands an added level of expertise. 

Clinicians need to be able to differentiate between the medical effects of binging, purging and starvation and the psychological effects of an eating disorder itself. They need to learn when to seek not only psychiatric help but medical help and work together closely on a team that attends to chronic medical issues. They need to understand the different levels of care available to patients, not only to choose between them but to understand if these options are even appropriate. 

Even more importantly, clinicians need to be aware that eating disorders cause severe medical problems and have the highest rate of death of all mental illnesses. Leaving one's fate to a minimally trained clinician seems foolhardy. 

It's best for patients to seek clinicians who claim expertise and significant experience treating people with eating disorders and then to ask in more detail about that experience and about possible treatment plans. The answers to those questions can give a lot of information quickly. 

Also finding a primary therapist with experience is likely to open treatment up to a team of clinicians who can start one's path to recovery. Wasting time seeking help from people with limited experience will only extend the time of suffering.


Individualized Eating Disorder Treatment

The standard treatment protocol for someone with a moderate to severe eating disorder is clear. Establish treatment with a team including a therapist, nutritionist and physician. Fully assess the medical and psychological state of the patient. Determine the appropriate level of care: outpatient team, outpatient program, residential program or hospital. Begin treatment. 

This standard approach is considered to be fairly straightforward. Like many other illnesses, the existence of a protocol implies that following the plan will lead to recovery. In the case of eating disorders, this is often not the case. 

The limited data supporting success of this treatment plan leave clinicians with their intuition and experience to make decisions rather than hard information to rely on. The promise that any step in treatment guarantees health and recovery is empty. 

The truth is that each person with an eating disorder needs an individualized treatment plan. The direction of treatment may often follow a standard protocol, but each step forward must be evaluated to see if it is right for the patient. It's not acceptable to confuse a failed treatment direction with low patient motivation. The key is to find a plan that works and not blame the person with the illness if the intervention doesn't help. 

Thus, I usually advise patients to find treatment providers they think they can trust and feel comfortable with. Also be sure this team is willing to collaborate on decision making. Having agency in one's life is essential to feel like recovery is really about wellness and life, not just following someone else's plan. Last, be sure everyone's goal is to create both recovery and a full life. Any other distractions or ulterior motives will only interfere with what recovery is all about.


Why is an Eating Disorder like a Virus?

The nature of an eating disorder is fluid and constantly changeable. Even though the thoughts and symptoms often seem fixed, any change in situation, context or environment will precipitate an immediate adjustment in the eating disorder. In this way it is like a virus in the mind, always ready to adapt to new surroundings, multiply and attack. This ability keeps the eating disorder powerful and enables it to dominate a life. 

For instance, when someone with an eating disorder moves to a new environment, the rules instantly change to suit the situation, mostly in order to maintain strict control over food. A new relationship will lead an eating disorder to find a way to inject itself into a situation. Changes in a food plan precipitate other, often hidden, changes to compensate.  

Paying attention to the subtle response of an eating disorder and fighting to avoid those pitfalls are challenging yet necessary in recovery. 

The ever-changing, insidious quality of an eating disorder demands a consistent, flexible treatment team. The people who comprise that team need to understand each other, be capable of quick response and be very familiar with each other's thought processes about recovery. There can't be a secondary agenda. The team can't isolate from each other and compartmentalize aspects of treatment. Working as a cohesive, directed unit will increase the likelihood of success and also take the responsibility of managing the team out of the patient's hands. 

From a biological perspective, a treatment team needs to mimic the effectiveness of antiviral medications. Viruses are highly adaptable organisms which can mutate in the blink of an eye to a new environment or to new medications. Any success treating viral infections stems from anticipating the likely responses of the virus to new treatment and blocking off all avenues of escape. 

The analogy is very similar for eating disorder treatment. If a clinical team can block off ways the disorder mutates, the person has a real chance of recovery. This level of success may scare some patients who aren't psychological ready for such a big step in recovery, but realizing recovery is possible can have a profound effect on even the sickest patients. 

A patient can identify a team working this well when it appears the clinicians work together fluidly and seamlessly. If a patient needs to manage the team, then there is a problem. If the team members need to spend lot of time getting on the same page, then that is also an issue which detracts from recovery and opens the door for the eating disorder to flourish. 

A treatment team is a crucial part of recovery. But finding any team isn't enough. Cohesive support aimed at cornering an eating disorder can make all the difference in true recovery.