The Increased Risk of Developing Eating Disorder as an Adolescent

I am going to highlight some important posts from the past ten years and repost them over the next few months. Here is the first one about why the risk of developing an eating disorder during adolescence is so high.

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 has 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-terms 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. 

Treatment Bias in the Eating Disorder Community: Race, Gender and Age

Eating disorders have been associated with young white women in a high socioeconomic bracket since the inception of these illnesses in the 1970’s and 1980’s. As the incidence of eating disorders has grown significantly in recent decades, research has proven that the power of the diet culture, obsession with thinness and inexorable pull towards weight loss by any means has not discriminated by race, age or gender.

But eating disorder treatment remains very much focused on the original population who first became sick. Therapy, treatment philosophies and residential programs are all geared to young white women of means. The eating disorder treatment world does not make room for other people suffering with these illnesses. African Americans are much less likely to receive eating disorder referrals from their doctor. Men struggle to find any treatment open to them. Older patients are marginalized by a clinical culture that stigmatizes them as untreatable.

Much of this stigma stems from the cultural lie about eating disorders: a person cannot be sick unless they look very underweight. This misunderstanding of eating disorders remains the central diagnostic criterion to doctors, clinicians, families and lay people. Time and again, people say someone cannot be really sick unless they look emaciated.

Meanwhile, all eating disorders, including anorexia, can be serious and severe when people have many different shapes and sizes. Weight and shape are not a good indicator of severe illness. A full assessment of the patient is the only way to understand how sick they are.

Basing someone’s illness on body shape immediately discriminates. On the whole, marginalized people in the eating disorder world are the ones who are unlikely to fit the socially acceptable code for an eating disorder. Only young white women are likely to become emaciated enough to receive attention and a referral.

Facing diet culture and fat phobia also means seeing the inherent racism and bias associated with how clinicians diagnose people with eating disorders. We clinicians need to understand that our own internal racist, sexist and ageist beliefs cannot cloud our clinical judgment. Size, age and gender are not ways to understand someone’s eating disorder. Only a full examination and use of unbiased clinical judgment will allow for fair and equal treatment for all people who need it.

Please find a few resources below to explain more about the bias in eating disorder diagnosis and treatment:

https://www.nationaleatingdisorders.org/people-color-and-eating-disorders

https://www.npr.org/sections/health-shots/2019/03/03/699410379/when-it-comes-to-race-eating-disorders-dont-discriminate

https://centerfordiscovery.com/blog/overcoming-an-eating-disorder-minorities/

Recovery in these Challenging Times

In the midst of the pandemic, the protests and the violence, everyone is reeling as they try to figure out how to manage. Most people are overwhelmed with their own emotions while also making sense of how to respond to the randomness of nature, the destruction wrought by humanity and the injustice and inequality around us.

How can someone caught in their own recovery from an eating disorder stay present for what is happening in the world and not lose sight of their own personal health?

It’s too easy to say this is not the time to fight for recovery. Instead just focus on surviving now and deal with the eating disorder later.

The problem is that eating disorders don’t stay stagnant while someone deals with the state of our world. It digs in deeper, becomes more powerful and sinks that person further into illness.

The only other choice is to both face the reality in front of all of us and stay present in recovery. Doing both things means staying true to who you are. Each of us needs to manage our own personal lives and find our own way to look at the current events unfolding around us.

It is crucial not to let these events distract from the goal of eating disorder recovery. Food logs, meal plans and journals to log emotions and personal responses remain as important as ever. These cornerstones of recovery serve as the way to stay connected with yourself and not pretend the eating disorder is the true core of one’s identity.

Continuing to attend all appointments for recovery provides opportunities to clarify thoughts and feelings and decrease the likelihood of leaning on eating disorder behaviors to cope.

Last, the more one uses the eating disorder to manage, the less true one’s voice becomes in the world right now. Thoughts and feelings need to stem from each of our own true and genuine selves and need to reflect the most honest place we can find in ourselves to see our world when it faces such an important crisis. The eating disorder will only cloud the truth behind the inanity of obsessing about food and weight.

Now is the time to focus on connecting with ourselves, our community and the people around us, not with a destructive illness.

Overcoming Judgment and Bias from Eating Disorder Clinicians

When people struggling with eating disorders seek help, they often feel like they are not really seen. Clinicians react so strongly to the disorder itself, they forget to see the actual person.

The focus on body, weight or health overrides the true person who sits in front of the practitioner. This is a human being seeking help for their own personal struggle. First and foremost, they deserve to be treated as an individual who was brave enough to show up for an appointment.

The problem is that eating disorders engender very strong reactions from clinicians or doctors.

Anorexia draws fear from almost all practitioners that this person may get very sick or even die. So almost every response translates into the fact that it’s time to go to a residential program or hospital.

Bulimia similarly brings out fear but also disgust. It can be hard for clinicians not to judge people with this illness and struggle to take the important step to see how and why this person is suffering so much.

Binging or compulsive overeating immediately leads to the inherent fatphobia in our society. Rather than work to understand the reason for the eating behaviors, treatment focuses on weight and potential health risks when many of these risks are fabricated by the medical establishment and diet industry.

Some of these concerns are real. Consistent starvation will lead to significant medical risks. Bulimia has medical risks as well. Binging causes enormous distress.

However, any doctor or clinician needs to temper those immediate concerns. The person who seeks help is searching for answers as well. They are aware that the psychological and physical manifestations of the eating disorder affect their lives. That’s why they came for support in the first place.

Any eating disorder clinician needs to see a patient as a person first. They need to understand the root for the behaviors and thoughts and establish a relationship with this actual person. That means putting away the biases around body, weight and food behaviors in order to establish a therapeutic relationship built on trust.

Any improvement in eating or health is important, but in the end these changes are meaningless unless they come from a foundation of emotional understanding and change. The eating disorder clinical world can embrace compassion over judgment, kindness over bias in order to help people start a path to health and recovery.

Disordered Thinking in Anorexia: the Most Concerning Symptom

A complicated aspect of anorexia is the underlying belief early in the illness that one is not truly sick.

Disordered thinking is a psychiatric term that means one’s brain cannot follow facts logically and cannot process information correctly. In other illnesses, examples of disordered thinking are paranoid thoughts, an inability to make sense and delusions (a fixed false belief) about the world.

Some eating disorder symptoms begin to appear somewhat disordered but never represent overall disordered thinking, such as body image distortion or wildly overestimating the calories of food.

However, severe anorexia does have one thought process that appears disordered. In some of the worst cases of anorexia, people don’t believe they are truly sick. Sometimes people who are clearly underweight can’t see it. Others who are eating very little food in a day believe their body doesn’t need more. In the worst case scenario, people with significant medical problems from their illness cannot believe they are truly sick. These people may be shown irrefutable evidence of their illness and simply do not believe it.

The disordered thought process in anorexia is important for another reason. These cases are the most severe and have a likely chance of chronic illness and early death.

Tackling and challenging this thought process is imperative. In less severe cases, the standard treatment is nourishment and restoration of health because some issues with brain function reverse with food. In the most severe cases, food doesn’t change the underlying thoughts and may reinforce them because any weight gain only solidifies the disordered thoughts.

For these patients, it’s critical to have therapy focus on questioning these thoughts. The goals are to present the case for why the anorexia is severe over and over again. The disordered thoughts give the patient relief since they justify the need to restrict. Instead therapy needs to make the person question these thoughts each day. The risk of the disordered thoughts is that they become an undeniable truth. If that is too solidified, the chance of recovery goes down significantly.

It’s necessary for the person to know that this battle between disordered, untrue thoughts and the unpleasant reality needs to be the crux of treatment. Without a clear sense of the truth, all therapy will seem meaningless and the anorexia will take over completely.

Starting Treatment for an Eating Disorder during the Pandemic

For many people, the pandemic can be a reason to delay starting treatment for an eating disorder. Virtual treatment is not a valid justification to allow an eating disorder to continue to dominate your life.

Eating disorders rule one’s life and make it so difficult to forge a path. The eating disorder thoughts and behaviors can take up more and more time each day. The lack of structure for many people during this time allows the eating disorder even more footing, especially if that person is not in treatment.

As I described in the last post, virtual therapy is very effective and may even have some benefits for people starting eating disorder treatment. The main positive aspect is around body image thoughts. Not being in a room with a new therapist is easier than feeling physically exposed by being face to face.

The time and lack of structure actually give recovery a lot more room to try to make a dent in the disorder. Logging food is more possible. Connecting in between sessions, writing about emotional reactions to food and changing meal plans all can happen now without distraction.

In addition, it’s easier to meet with a few people in order to find the right therapist, another critical part of determining the best path to move forward.

Last virtual therapy can allow for a true bond to form to fight the eating disorder just as much as in person therapy. Any step into recovery matters. In times like these, the illness can take over more or it can galvanize a person to put their all into changing their life.

The Pros for Virtual Therapy for an Eating Disorder

Virtual therapy by video or phone is the current new norm and has been a part of my practice for many years, although never the exclusive form of treatment until now.

Traditional psychotherapy always valued the therapist and patient in a private, safe room together. This framework has been considered essential to effective work.

There is truth to this therapeutic axiom, but eating disorder treatment has different needs that can be well suited to virtual therapy. Two specific and important components of eating disorder treatment come to mind.

First, a critical part of eating disorder therapy is distorted body image. Typically, therapists who treat people with eating disorders have pillows or blankets available for people to cover their body during the session. Seeing one’s body can be upsetting and distracting during the session, so covering up can actually make the session more productive.

Virtual therapy obviated the need for a pillow or blanket. Phone or video takes away the experience of being seen by the therapist and immediately focuses on the work at hand rather than a need to cover up in order to feel comfortable.

With the physical body image less central to the treatment in a virtual format, it can be easier to dive into important work more quickly. However, at the end of the session, deeper work leaves the patient feeling more exposed and vulnerable.

Many people in the therapist’s office might subconsciously begin to pull back from this work towards the end of a session since they know they will leave soon and have to face the world again.

In a virtual session, they are already in a safe space. So if the session ends at an emotional or vulnerable place, they will be somewhere that allows them time to regroup before restarting their day.

The virtual sessions take away two significant obstacles for effective treatment: the physical self and the act of going back into the world after the session.

Although the in person sessions provide a sense of safety together in the office, these two benefits from virtual sessions often lead to very effective treatment as well.

Quarantine and Eating Disorders, Part II

Although some people have been able to use this period as a time to take steps forward in recovery, others have struggled more with their eating disorder.

The constant stress and pressure of the pandemic have affected everyone, no matter their psychological state before. The barrage of news, the pause on life and the lack of contact have affected daily life for everyone. As this period has extended for weeks and weeks, it has taken its toll.

By and large, people have relied on tried and true coping mechanisms to manage the stress. For people with eating disorders, that has often meant a gradual escalation of symptoms.

Even if the intention is to maintain any gains or to stop the creep of worsening behaviors, many have found the eating disorder has started to infiltrate the extra time in their lives whether it means more food behaviors, worsening thoughts or increased exercise. We are all relying on what helps most during times of stress, and that is the same for people with eating disorders.

Few people have stayed in place with respect to their eating disorder. Most have either moved forward either seeing this time is a pseudo-program, as explained in the last post, or else drifted into worsening symptoms to cope with the stress.

The people who have seen this as a type of treatment entered the quarantine already primed to focus on recovery. That means having either just left a treatment program or just resolved to try to get well.

Those who are seeing an escalation of symptoms tend to have already been in a steady place with their eating disorder or struggling to find ways to get better.

Eating disorders always seem to be changing. Either the situation is improving or worsening most of the time. This pandemic appears to have escalated the pace of change for many people with eating disorders.

However, for those who want help, the support is available and just as effective remotely as in person. This is not a time to despair or wait. It’s as good a time as any to try to move forward with recovery.

The Daily Calm of the Lockdown in Recovery

Adjusting to the pandemic lockdown has been difficult for most everyone. For me, one causality was this blog. With over a month to understand how the coronavirus has affected people with eating disorders, I have had many thoughts I will share over the new few posts.

First, people have a wide range of reactions to the overall situation in the world, our country and our individual communities. There is no right or wrong way to manage the lockdown. This truth applies to people in recovery as well.

The increased stress of dealing with life on pause and the fear of a serious and contagious disease has led many people to rely on old coping mechanisms. For many this has meant leaning on eating disorders thoughts more.

However, the lack of overall stimuli from the world also gave an opportunity for most people in recovery to reflect on the worsening thoughts before acting on them. Interestingly, although these thoughts often worsen, behaviors don’t necessarily follow.

Daily routines are slower and quieter for most of us since our main objective is to be home and safe. So even when thoughts increase, there is ample time and space to try to separate from the eating disorder thoughts and use skills to avoid behaviors.

Accordingly, most people in recovery have not relapsed. Most people attempting to take new steps in recovery have found a way to try to move forward now. And most people have the energy to complete food journals, do the necessary work between appts and engage fully in sessions.

More than one person has likened the time at home to a more loosely organized residential treatment program. Everyone is home and cannot go anywhere, and the food is always there and available with few built in excuses to avoid it. However, the biggest difference is that everyone is making their own food decisions. Nothing is imposed by a treatment program so any progress is based on one’s own desire to get better.

So for many this lockdown has become an opportunity to further recover, something I never would have imagine a month ago.I’ll dive in with more details in the next post.

Treating Anorexia as a Process of Reprogramming

Anorexia is one of the most intransigent psychiatric illnesses to treat, certainly much harder than any other eating disorder.

In this blog, I have written extensively about the eating disorder thought process of anorexia. People often experience it as screaming in their head, almost a person’s voice telling them what to do. The more they disobey these thoughts, the louder the screams get.

These are not psychotic symptoms which entail people hearing or seeing things that aren’t there. These voices are thoughts in one’s mind, disembodied thoughts that don’t fully seem like one’s own individual thoughts.

The person with anorexia often feels taken over by the thoughts to the point that their own thoughts and feelings are pushed aside and replaced by the eating disorder. One’s personality, wishes and feelings all become secondary to the demands of the eating disorder thoughts.

Successful therapy for severe anorexia can often feel like reprogramming: a process of unearthing the person’s true thoughts and feelings after years of being buried under the illness. The treatment involves creating a strong bond between the therapist and actual person to help the person to question the eating disorder thoughts and motives.

Once the person begins to question the thoughts, it leads to the possibility of considering others options. Is being so starved actually something that improves one’s life? Does it feel good to be sick and weak? Is being underweight a true accomplishment? Why is it worth forgoing everything else in life that matters? Isn’t it better to have real relationships than only a relationship with your eating disorder?

These questions are a start, but even when the person can see the contradictions, questioning the anorexia still feels like betraying these thoughts that have protected the person, kept her safe and made sure she felt ok. The step towards reframing this concept of betrayal as a process of moving forward in one’s life is equally critical.

It is almost as if recovery from anorexia is a reprogramming after being brainwashed by this illness. I can’t think of another Illness that coopts brain function yet still leaves the rest of one’s abilities intact.

The next post will address a secondary effect of anorexia. Namely, how does the concept of anorexia as brainwashing open the door to the cult of the brilliant clinician?

Secondary Diagnoses with Eating Disorders

Diagnoses in psychiatry are inherently confusing. There are categories with several criteria for each illness. If a patient fulfills enough of the symptoms, they receive the diagnosis. There are no definitive tests or diagnostic scans but only empirical data clinicians use to agree on definitions of illness.

This approach to mental illness was created to codify a language clinicians use to communicate with each other. However, it also leaves many people with a handful of diagnoses—a grab bag of symptoms which mean very little to patients when thrown together.

This experience is common for people with eating disorders. Most often, people with eating disorders develop a number of other symptoms secondary to the chronic eating symptoms such as depression, anxiety or OCD. The list of diagnoses following an eating disorder on a chart is often of little value. Normalizing eating almost always eliminates these issues as well. In other words, the eating disorder is usually the primary problem.

Some patients who have been ill for some time are excited or hopeful about the idea that another diagnosis may be the core issue. Their hope is that this new diagnosis opens the door for a clearer path to wellness.

Unfortunately, a new understanding by a clinician gives false hope. Some secondary diagnoses solidify over time and appear to be primary, but that only reflects the hardened nature of the eating disorder in a person’s life rather than the new realization which solves all their issues.

Bipolar disorder and Post-Traumatic stress disorder are the two most common illnesses which turn out to be primary and the eating disorder just a manifestation of those symptoms. Treating the primary issue in these cases can lead to a more swift recovery.

Panic disorder, Major depression and Obsessive Compulsive Disorder typically are secondary diagnoses. Focusing on these issues rarely leads to eating disorder recovery. OCD can sometimes appear to be the primary issue, but long-standing restriction typically leads to OCD symptoms that can be very strong but still secondary.

It is important to recognize and treat secondary diagnoses. No clinician should ignore these issues; however, treatment needs to stay focused primarily on eating disorder recovery. Prolonged periods of abnormal eating lead to symptoms that mimic other psychiatric illnesses, but eating disorder treatment needs to remain the number one issue.

How Long Does it Take to Get Better from an Eating Disorder?

When first contacting me for treatment, people often ask how long it will take to get better. I hesitate before answering the question. There is never an easy answer because this question involves several layers of meaning.

First is the underlying fear that no one gets better from an eating disorder. This is a lay myth that reveals an ignorance of these illnesses and is patently untrue. Some people do remain chronically ill but many people do get better, and it’s essential that everyone entering treatment knows that full recovery is a realistic goal.

The second implication is the antithesis of the first: the desire to magically rid themselves of the eating disorder quickly, once and for all. Sadly, this is not how people get better. The eating disorder is comprised of ingrained eating patterns and well-worn thoughts about food and weight. It takes time to tease apart, analyze and change these elements of the eating disorder. Recovery is hard work that takes time, but well worth it.

Third is the fear of fully engaging in recovery. Whether conscious or not, the person is aware that fundamental aspects of their life needs to change in order to get better. This means embarking on an intense therapeutic relationship and significant changes in their life in order to escape the eating disorder. No matter how miserable an eating disorder can be, this level of change is daunting.

Last, this question infers a significant cost. Adequate treatment is a commitment of time, energy and money. Attempting true recovery means diverting a large portion of these crucial elements of life to a difficult process, one that can work but is not guaranteed to work. It takes courage to truly take the step towards getting well and give so much of oneself to the task.

So the answer to this simple question is fraught. I can’t say five or ten sessions. I can’t say it’s necessary to meet weekly, biweekly or monthly. I can’t say six months or a year. The answer is that I never know and can only tell once the treatment starts. The answer is rarely satisfactory, and the goal is just to get started with treatment.

How to Fight the Positive Feelings about an Eating Disorder

Unlike most psychiatric disorders, eating disorders become a comfort and source of pride to many people. Patients feel sick and miserable when trapped in their eating disorder yet often feel a sense of accomplishment from the idea of mastery of food and weight or pleasure in how they eat. Moreover, they often get a sense of relief and comfort from their symptoms that can be hard to replace.

A strong emotional attachment to an illness is unusual. It’s to be expected that almost always people want to get better from their illness. The ambivalence and identification with eating disorders makes them unique among mental illnesses.

Successful treatment cannot solely focus on managing symptoms and finding new ways to cope with stresses in life. Creating new eating patterns and countering the thoughts of an eating disorder also remain central. However, even these goals may only lead to temporary recovery. Something else needs to create enough motivation to fight against an illness so wrapped up in one’s pleasure and identity.

The last piece of recovery is finding an anchor in the real world. Specifically, someone with an eating disorder needs to identify at least as strongly and maybe more strongly with a desire or goal in their life outside the illness. This goal needs to be impossible to achieve while the eating disorder is dominant.

The conflict between this goal and the eating disorder forces the person to choose between life and the illness. Instead of arguing with a therapist about getting better, the conflict is now internal.

The external goal can be having a family, maintaining an intimate relationship, being physically well enough to achieve a goal or raising children. The goal must be of supreme importance to the person and driven solely by their own needs.

No therapist can help a person find these goals; however, a therapist can identify and reinforce that this goal really is important. The eating disorder thoughts can be so demoralizing and render the patient helpless, but support to remember the goals are achievable will make this conflict feel very real.

The other aspects of recovery are still just as important. However, internalizing the conflict by having real goals in life that cannot exist with the eating disorder opens the door to fill recovery.

The Risks and Benefits is Increased Communication for Eating Disorder Recovery

The relentless thought process of an eating disorder dominates the mind of someone who is sick all day and night. Recovery aims to replace these thoughts with healthier thoughts about eating a normal mean plan and overall health and well-being.

However, one or two sessions per week is much less powerful than the endless stream of eating disorder thoughts that lives with someone day and night. Contact in between sessions helps balance the playing field in the recovery process.

Technology has opened up many new ways for therapists and nutritionists to contact a patient during the week. Email, texts and various recovery apps allow for regular check-ins that can stem the tide of eating disorder thoughts and allow treatment to have a more pervasive effect blocking worsening symptoms.

The regular contact through the week goes against the grain of all mental health treatment. With consistent, daily contact—a mainstay of eating disorder recovery—the therapeutic relationship can blend into what also feels like a personal relationship. The clear boundaries imposed by regular time slots and contact only in the office are much less defined with all forms of messaging.

Many patients with eating disorders have some confusion around boundaries and relationships. Sometimes this issue stems from complicated family relationships, and for others it is due to the lack of experience of social contact due to the isolation caused by the illness.

The inherent confusion around the therapeutic relationship, an essential component of successful treatment, can easily be misinterpreted by clinicians and laypeople unfamiliar with eating disorders treatment as inappropriate.

Eating disorder clinicians are employing other means to try to protect the privacy and treatment from those who might jump to conclusions that the therapeutic relationship crosses boundaries. HIPAA summaries in the email signature, encrypted text and email apps or formulaic recovery apps are increasingly used in therapy. However, some clinicians are even shying away from communication in between sessions to avoid any confusion, even if it harms recovery.

If eating disorder treatment fit into the traditional therapy approach, there would be no need for alternate forms of care. Instead, standard approaches fail miserably.

For many reasons discussed in this blog over the years, the therapeutic relationship is the cornerstone for eating disorder recovery.

Even if that relationship is sometimes confusing and complicated, no treatment works without fully engaging with the patient to pull her out of the clutches of the eating disorder. Hopefully, education about the necessary components of eating disorder treatment will allow for more acceptance of this form of therapy.

Meal Plan After Bariatric Surgery

All Bariatric surgery shrinks the stomach down to a much smaller size than a typical stomach. The purpose of the surgery is to limit the amount of food a person can eat at one time. Eating more than this new stomach can hold leads to discomfort, pain and even vomiting.

The risk of overeating and the lack of familiarity with this newly transformed organ often leads to severe food restriction and a fear of eating. A significant number of people lose a lot of weight in the months after surgery because they are afraid or unable to eat enough.

Clearly, as explained in the last post, undereating is not a sustainable way to live. One possible result is surgical anorexia, and another option is a new form of disordered eating aimed at overcoming the limitations of having such a small stomach.

The most successful people after surgery learn a new, sustainable and reasonable way to eat. This new plan takes into account their caloric and nutritional needs, the capacity of their stomach and the rhythm of their daily life.

Sadly few nutritionists appear to focus on helping the many people who now have Bariatric surgery. The worst culprits are the ones who work in the Bariatric centers. Their sole goal appears to be short-term weight loss, the overall sign of success for these centers. Long-term health and quality of life rarely factor into their suggestions.

The new meal plans need to incorporate a few simple ideas.

First, meals need to be small, rarely more than a cup of food. This basic fact acknowledges the limitations of the new, small stomach.

Second, a cup of food is not enough to sustain someone more than a few hours. Thus, the typical plan of three meals and two snacks is rarely effective after surgery. Instead, a new meal plan needs to include eating a small to medium size amount of food more often through the day, usually every two hours or so. Instead of meals and snacks, this plan has mostly snacks.

Third, the food needs to be varied throughout the day. Since it is harder to eat enough due to the small stomach, the new plan needs to consider the nutritional value of the food to ensure one gets enough nutrients through the day. Typically, a varied diet will always include enough nutrition. Since a small stomach only allows limited food per day, it is important to be sure to eat enough nutritious food.

Essentially, people who have had Bariatric surgery have to manage a damaged stomach the rest of their lives. Just as anyone who has had an injury, these people can accommodate their diet to take into account the injury and ensure adequate nutrition.

Surgical Anorexia: the Long Term Effects of Bariatric Surgery

As a psychiatrist treating people with eating disorders, I find that I have specific but unexpected expertise to help people after Bariatric surgery. These procedures aimed at reducing weight induce what I have started to call surgical anorexia.

Chronic anorexia leads to poor functioning of many organ systems due to long-standing malnutrition including the gastrointestinal system. Slow digestion, an inability to tolerate many foods, delayed emptying of the stomach and poor absorption of energy and vitamins are ways anorexia can affect the GI system. Thus, poor nutrition damages the GI system and makes it more difficult to absorb the needed energy.

Bariatric surgery shrinks the size of the stomach significantly which leads to an inability to eat a normal amount of food at one time and to more difficulty absorbing nutrients and vitamins. Essentially, the surgery mimics the same GI symptoms that chronic anorexia causes. Over time, these GI symptoms lead to starvation and the same medical effects of anorexia unless steps are taken to ensure adequate nutrition. It’s not a stretch to call this surgical anorexia.

After the surgery, patients I have encountered receive minimal instruction about how to alter their diet and their eating pattern to accommodate their transformed GI system. They need to learn new foods to eat, how much they can tolerate and when to eat through the day. Nutritionists at Bariatric centers tend to give a formulaic meal plan without any detailed, individualized instruction about how to maintain a normal diet.

The end result is often a patient confused about how to eat, eating an insufficient about of food and, after a few months, experiencing symptoms of malnutrition and starvation. These symptoms include nausea, weakness, dizziness, trouble concentrating and irritability. Often patients are afraid they are sick and don’t understand they are starved. And the Bariatric programs refer patients to other doctors and don’t take responsibility for a common effect of Bariatric surgery: surgical anorexia.

In time, patients start to find ways to eat. They eat more often through the day. They eat foods that are easily digested. They start to drink alcohol which loosens the stomach muscles. They overeat or binge and purge but are able to absorb some foods. These are not constructive ways to manage food intake.

However, the longer they are starved, the more their body’s survival instinct kicks in. They start eating large quantities to assuage the starvation which leads to regaining any weight lost from the surgery. In other words, the lack of instruction after surgery means the effects of surgery are usually temporary and can trigger new disordered eating patterns.

Bariatric surgery is not the panacea people often hope it is, but many people seek the surgery after years of desperation. For those who do take this step, there are some basic facts about eating with a surgically damaged stomach that can help avoid surgical anorexia. I’ll discuss them in the next post.

The Philosophy of an Eating Disorder

Eating disorders often present a much more appealing and clear philosophy of the world to young people just starting their lives. For adolescents and young adults afraid of the unknown and the lack of clear guidelines for living, the certainty of the eating disorder rules can be very appealing.

These rules determine how one should feel, the overall goals for the day, how to determine a sense of accomplishment or failure and the best way to move through daily life.

The rules typically entail aiming for certain weight goals, clear rules around food and exercise and a way to decide which personal or profession al events to attend or skip. The eating disorder makes up these rules for one simple, straightforward goal: weight loss.

With this goal in mind, the other more vague goals of life go by the wayside. All other potentially important aspects of living pale in comparison to the concrete and simple goals around food and weight. Life becomes simple, and the philosophy boils down to one measure of success.

Even though eating disorders can seem nonsensical or even vain to many, these illnesses present a lure to young people scared about the uncertainty of life and looking for a way to take away the prospect of having to make decisions in a very confusing world. The eating disorder is an easy out from daily life into a very simple way of life.

The reality of living in the eating disorder world is that young people don’t learn basic life skills: developing friendships and relationships, managing emotions through a normal day or making decisions as an adult.

When entering recovery, people often feel lost without any means to cope when they cannot rely on their eating disorder anymore. The immediacy of relationships, emotions and decisions can quickly feel overwhelming.

Getting better from an eating disorder isn’t only about learning how to eat and manage a healthy body. It also means learning how to face the vagaries of life without a parallel set of rules dictating how to live.

In the end, recovery must focus on living without an eating disorder. It means a crash course in developing coping skills, interpreting internal reactions and stimuli and managing the uncertainty of life as we all must.

It’s a tall order while also learning how to eat and makes the entire process hard. Successful recovery needs to entail the process of learning how to live as much as the process of learning how to eat.

Emotional Maturation during Recovery

Once eating is largely normal and behaviors mostly diminished in recovery, there is room for emotional and psychological development that is impossible in the throes of an eating disorder.

The disorder in full swing is debilitating. Disordered eating and obsessive thoughts about food dominate one’s mind. In addition, completing the eating disorder tasks and following the rules feels like an accomplishment each day. These goals trump all other aspects of daily life and leave no room for other ways to grow into yourself.

After the symptoms subside, the person in recovery faces the realities of life in new ways. The trials and tribulations of work, family, friends, relationships and personal growth all come to the fore very quickly.

Without the guideposts of the eating disorder lighting the way, the uncertainty, confusion and emotions of life feel overwhelming and confusing very quickly.

The months or years of development that would occur otherwise stop almost completely when an eating disorder is present. Most relationships stagnate and all emotions disappear under the intense pressure of the eating disorder rules.

Emotional and psychological development in the process of recovery entails learning how to manage relationships and friendships, identifying emotions, finding ways to cope with life events and managing the uncertainty of daily life. In an eating disorder, none of these issues truly matter. All that demands attention is food and weight.

Fortunately, the period of development for someone in recovery is usually fast and furious. Once the eating symptoms subside, emotional maturing begins immediately.

Although the process is challenging and scary, the mind has developed even though the psychological changes have not occurred. So one’s mind is ready to charge ahead and learn all the components of development and maturity quickly. It’s important for the person to have help identifying emotions and learning new ways to cope with a world no longer guided by this illness.

Focusing on emotional and psychological development solidifies the gains in recovery and, in the end, makes it hard to return to the illness. The success of managing life with an eating disorder, as hard as it can be, well outweighs the misery of being trapped in this illness.