Eating Disorder Recovery is Grounded in Connection

The last few posts outlined new directions for eating disorder diagnosis and treatment. Conversations between people with eating disorders and the openness and ease of communication using social media open doors to new links between eating disorders and other illnesses and new treatment ideas as well.

However, it bears repeating that the psychological underpinnings of eating disorders are the most important reasons people have so much difficulty getting well.

The various emotional effects of both eating disorder behaviors and thoughts are incredibly powerful and keep people entrenched in their disorder.

Eating disorders can create excitement and also numb feelings; they can cause calming structure or deliberate chaos; they can offer clear moral guidelines for life or offer a lofty but ultimately unattainable goal.

In the end, eating disorders offer a solution to the challenges of connection in our lives. The connection with the eating disorder supplants connection with ourselves, other people, our emotions and our body. The eating disorder stops people from connecting in a true and deep way with others.

Any successful treatment needs to include learning how to connect with oneself and with others as a fundamental antidote to the allure of the eating disorder. Most people with eating disorders have had limited connection in one or all of these forms, and treatment helps them learn about the fundamental human need for connection and how to find it.

Typically, learning about connection starts in therapy. That experience is in part didactic but often it is also experiential through learning about connection through the safe and boundaried relationship in the therapy. The therapist creates a space that is safe, warm, open and validating. There needs to be room for all sorts of experiences and feelings in therapy so the person can learn to be open and accepting of their own emotional experiences and needs.

With these newfound ideas about self-worth, feelings and connection, people with eating disorders can conceive of a world less reliant on the eating disorder to satisfy those emotions.

So even though a broader idea of diagnosis will benefit many people with eating disorders, any recovery has to include profound learning about emotions and connection.

The Generator of Progress in Eating Disorder Care: Social Media

Progress in diagnosis and treatment in psychiatry historically relies on the experience and knowledge of clinicians who use their time with patients, educate themselves about new treatment ideas and collaborate with colleagues to further the field and hopefully improve overall clinical care.

Social media opens a new door to how the field progresses. Patients themselves express original ideas based on their lived experience and communicate with each other to find ways to assess and even consider new treatment for their condition. And this new path is starting to affect progress in psychiatry.

One result is to connect other medical and psychiatric illnesses to eating disorders, as I wrote about in the last two posts. People are communicating with other patients about these connections and bringing to light new ways to conceive of eating disorders.

The medical establishment, however, has not yet caught up with the findings. Clinical work remains fixed in older ways to treat eating disorders. Accordingly, patients come to treatment with new ideas about the individual symptoms and possible treatment for their own eating disorders and then try to find clinicians willing to work with them.

Social media has changed the way psychiatry is going to treat patients with eating disorders. The more difficult the disorders are to treat, the more patients are likely to look into alternative options and shop for doctors open to these new ideas.

So clinicians need to take these new concepts into account. Moreover, comprehensive assessment of eating disorders, including concomitant psychiatric and medical conditions, is imperative.

Patients will find other ways to get the help they need by cobbling together doctors who will do separate assessments and then find their own individual way to try to get well. The more clinicians band together to create a better way to assess eating disorders, the less patients will feel compelled to try to piece together their own treatment.

Treatment is no longer clinicians diagnosing and making treatment plans. The process of eating disorder treatment needs to be collaborative.

The Need for Inclusive Eating Disorder Treatment

Typically eating disorders are treated as psychological illnesses. A doctor manages any medical symptoms, lab abnormalities and medications, but the primary work in recovery is mental and emotional in nature. The root cause of an eating disorder is almost always seen as a mental health issue.

For many people with eating disorders, this paradigm is accurate. Separation and individuation from an enmeshed parent relationship, numbing of emotions from traumatic experiences and the strong desire to avoid adulthood are still common initial events that lead to an eating disorder. Treatment still needs to encompass these clinical situations.

However, more correlative data links eating disorders with other medical and psychiatric disorders—a connection elucidated in the last post. Treating these concomitant, if not perhaps causative, illnesses falls outside the purview of typical eating disorder treatment.

For instance, chronic inflammatory illnesses such as MCAS or general autoimmune symptoms may be alleviated through eating disorder symptoms. The same may be true for people with chronic metabolic issues. If these patients recover from their eating disorder, the medical symptoms return and often worsen; thus, recovery needs to address these other medical issues to allow people to recover and manage these other illnesses too.

Similarly, eating disorder symptoms may help mitigate some psychiatric symptoms for people with untreated ADHD or undiagnosed autism. Eating disorder recovery that doesn’t address these other disorders won’t be helpful for true recovery.

Eating disorder treatment not only needs to screen for other connected medical or psychiatric illnesses but also needs to incorporate a more complete approach to allow for full recovery.

The standard psychiatric treatment screens out many people with other comorbid medical or psychiatric illnesses when the approach needs to be more inclusive. These other patients deserve more complete treatment too.

A New Approach to Eating Disorder Assessment and Care

The assessment, diagnosis and treatment plan for people with eating disorders has changed dramatically in recent years.

Historically, the initial appointment comprised of a standard psychological intake followed by medical, therapeutic and nutritional follow-up. These components are still essential to any treatment plan.

Eating disorder symptoms clinically appear to be connected to other biological systems as well, predominantly metabolic, endocrine and immune (autoimmune disorder and Mast Cell Activation Syndrome). In addition, there has been more data connecting other psychiatric disorders such as Attention Deficit Disorder (ADHD) or Autism Spectrum Disorder (ASD) with eating disorders as well.

It’s unclear whether these connections are causative or even possibly point to a different way to conceive of eating disorders. Despite the lack of relevant information, diagnosing and treating these concomitant illnesses aids eating disorder treatment for many people.

A clinician now needs to take into account this entire set of medical and mental health considerations as well when developing a plan for treatment. Medicine may not yet know how and why these organ systems or psychiatric disorders seem connected to eating disorders, but distinguishing different causes and symptoms related to each person’s illness can enable a clinician to individualize treatment.

The holy grail of medical and psychological research into treating eating disorders is finding an underlying biological cause. Through such a breakthrough, the long lasting torment of these illnesses might be shortened significantly.

The ingrained behavior patterns of an eating disorder become entrenched so behavioral therapy would still be indicated, but combining a medically-informed treatment with therapy might shorten the length of care needed to get well.

A thorough assessment needs to include several elements.

1. Psychological evaluation
2. Nutritional assessment
3. General medical exam
4. Labs tailored to assess metabolic function
5. Assessment of inflammatory symptoms
6. Screening for attentional deficit or autism spectrum when indicated

The combination of a standard psychiatric evaluation plus the extended assessment for other associated conditions will help determine the best course of treatment for any individual and increase the chance for a successful outcome.

Identity Transformation at the Center of Eating Disorder Recovery

Most chronic illnesses, medical or psychiatric, have a significant impact on a person’s quality of life. Coming to terms with an illness not easily managed or cured changes how someone sees their life trajectory and future. Although an illness can become a part of the lens through which one sees the world, eating disorders are unusual in how they become tightly woven into one’s sense of self.

No matter how the eating disorder starts, the symptoms, self-image and behaviors around food become paramount. All decisions center around the convenience or difficulty of eating or around what the eating disorder seems doable or acceptable.

Inevitably, the way one thinks of themselves and leads their lives depends largely on the eating disorder. Social events, professional choices and any personal plans revolve around what is best for the eating disorder.

Since eating disorders—or at a minimum eating disorder thoughts—start at a young age, psychological and emotional development occurs with the strong eating disorder thoughts influencing every decision. One’s identity and eating disorder grow up together, connected in the overarching experience of learning about oneself.

At its core, eating disorder treatment isn’t just normalizing eating behaviors and regulating body function, nor is it simply relearning new ways to think about hunger and fullness.

Recovery involves breaking down one’s own identity and building a new identity from scratch, no matter your age or personal situation, based solely on one’s own self and not the tenets of an illness.

It’s hard enough to take the steps towards recovery let alone imagine that recovery involves such a profound and painful emotional process, one that adults rarely if ever need to consider.

Time and again, clinicians working with people with eating disorders see this trajectory. Recovery is hard work starting with eating the food and handling changes in one’s body. Understanding the internal transformation that ensues is the next big step followed by a willingness and ability to forge ahead and find that true self, separate and free of the eating disorder.

One Key Limitation to Expanded Eating Disorder Care

Eating disorder treatment and recovery isn’t just about mind over matter. Access to so many types of clinical care, in person and online, doesn’t change the intractability of an eating disorder—illnesses that are physiological as well as emotional.

The psychological draw of an eating disorder can be powerful in many ways, for example the emotional numbing through the release from overeating/binging or the protection from traumatic symptoms via restriction. Over time, the repeated disordered eating behaviors can engender a physiological response in the body’s gastrointestinal system which adapts to the new disordered eating. Once their bodies get used to this new pattern, people have a much harder time escaping the entrenched behaviors.

Many people use food in emotional ways, but not everyone is wired so that the initial manipulation of food becomes a full-fledged eating disorder. For some normal eating returns, and for others the behaviors lead to an eating disorder.

Any treatment needs to take into account the necessary steps to normalize food, track the healing and regulation of various organ systems and engage the resiliency of the gastrointestinal system both for digestion and for hunger/fullness. The physical healing almost always precedes the emotional healing. The body needs to function first for the mind to follow.

Most of the newer support systems focus on the emotional and psychological healing. In many ways these programs are modeled on the older, more established network of treatments available for substance abuse. The treatments are very educational; patients and families alike are much more informed about eating disorders than ever before. But the programs need to include the medical aspect of eating disorder recovery as well.

Without the focus on physical healing, the risk in treatment is for many people to make emotional strides and remain physically sick, unable to make consistent progress with normal eating and gastrointestinal function.

Treatment programs help to a point, but too many people experience programs as intrusive, as if people have to endure forced eating which they can reverse once discharged back into their lives. All the more recent chatter about weight loss drugs and surgeries in recent years only reinforces the glorification of thinness.

Expanded access to treatment has greatly improved the education about necessary emotional and psychological strides for recovery. These illnesses are known to be intractable for a reason, and the entrenched physiological effects are a major cause. It’s the job of any clinician to recognize this fact and be sure to include physical and psychological needs in any treatment.

What Treatment Loses with Telehealth

Telehealth in therapy is here to stay. The abrupt transition to remote treatment in eating disorder work during the pandemic was noteworthy. There won’t be a return to mostly in person appointments. That ship has sailed. We all—clinicians and patients—have agreed to this new method of treatment.

It’s clear what has been gained from telehealth: increased access, convenience and new programs for in home treatment.

The practical considerations of treatment work well remotely. Monitoring food, cognitive tools to combat eating disorder thoughts and even group sessions for people with similar recovery experiences are all effective in this new modality.

However, another equally important question, one that few people are asking, is what have we lost?

Eating disorders require secrecy, isolation and obfuscation to remain powerful in a person’s life. These behaviors aren’t nefarious. In order to stay sick, people with eating disorders need to hide what they are regularly doing. Remote treatment can’t address the secrecy easily.

The screen provides an easy means for people with eating disorders to hide. They can hide their bodies. They can hide their thoughts and feelings. They can hide their behaviors. They can hide their true selves and create enough of a persona to slide by unnoticed.

And that’s what people with eating disorders find themselves doing. They remain unseen in the world and feel safe and protected. The thoughts and behaviors that structure their lives stay omnipresent, and the remote work means no one can ever really spend time with them, can fully see them.

I am an advocate for at least some in person sessions, especially with a therapist. Telehealth will work to a point. Symptoms will improve, but the fundamental emotional and psychological work will lag unless the therapy relationship has an in person component.

The Effect of Social Media Exposure in Eating Disorder Treatment

Social media has changed eating disorder diagnosis and recovery greatly in recent years. Long before seeking help, most people these days are aware of their eating disorder, have read, listened to or watched media that explained not only the disorders but various symptoms and the path of recovery. Thus, education about eating disorders is now largely delegated to online platforms so therapists can both clarify what people learn online and individualize treatment for each person.

Patients used to start treatment often more confused about the diagnosis and without much knowledge of treatment. Now any clinician in this field must assume a new patient is aware of diagnoses and has a lot of information at their finger tips. And since social media posts about eating disorders are very specific about thoughts and symptoms, people are often aware of subtle and specific elements of their disorder.

Treatment needs to incorporate this added knowledge into the therapy relationship and also to respect the vantage point of all patients seeking help. They enter the relationship with a lot of exposure matched with the personal knowledge of their own eating disorder. In fact, their experience needs to dictate treatment much more than ever before.

A therapist can tailor the information the patient has and use their own experience to guide therapy while simultaneously recognizing that this person’s knowledge must play a vital role going forward.

In many ways, this new entry point into eating disorder treatment is preferable. It levels the playing field. The therapy is immediately a partnership—a crucial element of most successful recovery.

There are a few caveats. Not all information online is true, but that can be easily discussed. Younger people and adolescents may need more guidance to assimilate the social media exposure into effective therapy. More information to assuage fears of what treatment looks like will be useful to counter the recovery stories with more difficult outcomes.

Ultimately, the therapist needs to respect the knowledge, exposure and introspection that precedes starting treatment. The effect of the availability of information about eating disorder can and should improve treatment and outcomes.

What will the Ozempic World Look Like? Part 2

The recent posts in this blog hypothesize about changes in our relationship with food and our bodies after the advent and proliferation of GLP-1 agonists like Ozempic and Mounjaro. To be clear, many beneficial purposes for these drugs exist: diabetes and metabolic issues, to name two important ones.

But this new class of drugs also lands squarely in the camp of life enhancers, not just medications to treat illness. What I mean by this term is drugs with benefits people deem attractive but not necessarily therapeutic. Stimulants like Adderall are a good example of a drug people use for extended hours of focus or appetite suppression and not always for the medical indication, ADHD.

Right now the craze for these drugs is largely based on how new they are and how inaccessible they can be. Over time, they’ll become cheaper and more available. Doctors will prescribe them even more freely. Like it or not, GLP-1 agonists are going to be part of our culture.

We need to expect and accept that people won’t have clear hunger cues, will lose and gain weight easily and repeatedly and will raise children who, in a post-GLP-1 agonist world, believe hunger and weight are malleable and controllable factors of life.

Granted, we all have been living in a world trending in this direction for years. There used to be room for changing norms of body shape and size. Industry and capitalism have hardened the glorification of thinness in ways that are going to be next to impossible to undo. With these new drugs and doctors’ obsession with weight loss, the pharmaceutical and medical industries mean these norms are here to stay.

A concomitant result is the permanence of eating disorders. The nature of these disorders will continue to grow and change in cultural ways as they have in recent decades. Eating disorders caused by GLP-1 agonists are the new frontier.

Since dieting and food restriction are the primary risk factors for eating disorders, we collectively have decided to allow the overvaluation of thinness to continue to condemn people to develop eating disorders.

Going forward, the goal is to catch and treat eating disorders early and aggressively. The clinicians who treat these illnesses can’t contain external factors but can increase education and awareness.

What will the Ozempic World Look Like?

Hunger is one the most powerful and essential ways our bodies communicate with us. Put simply, hunger prioritizes the need for food as sustenance and for survival.

The meaning of hunger has changed greatly due to a transformed food supply for many countries in recent decades. After centuries of food scarcity as the obstacle to survival, humans created societies with bountiful food, more than can be eaten and often with a huge amount of waste.

We aren’t designed to know how to handle excess food. Hunger is an acute feeling intended to focus all senses and thoughts on procuring food. Subtle hunger cues can be harder to assess, but the plentiful food for many people obfuscates hunger cues altogether.

The new world of excess food opened the door to many new approaches and industries aimed at manipulating our dulled hunger cues with the supposed intention of improved health but mostly aimed at weight loss.

These factors include diet culture, the obsession with thinness, unsubstantiated nutrition suggestions and ill-researched medical recommendations. Almost all of these ideas infer that our hunger cues are actually misleading. Instead, these new guidelines purport to show us the best way to eat.

Even though medications have suppressed hunger cues for decades, the new GLP-1 agonists practically turn off hunger for prolonged periods of time. No previous intervention has been so powerful. The advent of the medications—in addition to the over-valuation of thinness and limited attention to adequate nutrition—is posing new hazards to our well-being.

Typically, suppressed hunger led to significantly increased appetite, binging and weight gain. The body overreacts to long periods of undereating with a strong hunger response meant to promote survival. Older medications, Bariatric surgery and dieting all triggered subsequent increased and often uncontrolled hunger. Although people experience this reaction when going off these new drugs, what happens if they stay on them indefinitely?

The jury is out at the moment about long-term outcomes. If there are no unforeseen side effects that lead to pulling these drugs off the market, the GLP-1 agonists and the even more powerful medications coming down the pike are here to stay.

As physicians, we are likely to see people with similar medical consequences as with Anorexia or with other appetite suppressing interventions. Slowed digestion and gastrointestinal functioning is an inevitable and often a permanent result of decreased eating. Chronic malabsorption of various minerals and micronutrients can cause a host of diseases rarely seen in medicine and thus hard to diagnose. Slowed cognitive functioning almost always results from decreased nutrition. And this is just to name a few.

My best guess for the results in a society using this new medication routinely is a generally thinner population with chronic medical and psychological effects from the long-term effects of malnutrition. As much as medicine continues to conflate weight and health, we as a population will talk about getting healthier while in many ways we get sicker. It will be up to the country at large to decide if the sacrifice is worth it.

Hunger in the Ozempic Era

People with eating disorders are usually afraid of hunger. The advent of the long acting GLP-1 agonists like Ozempic and Mounjaro not only reinforce this fear but create an environment for a more widespread aversion to this basic human function.

Hunger cues represent one crucial way our bodies can communicate with us. The cues can be subtle like a feeling of emptiness in our stomachs or an increased interest in food, moderate like feeling a bit weak or irritable or strong like lightheadedness or a gnawing need to eat now to the exclusion of any other thoughts or desires.

No matter the level of urgency, hunger cues allow our bodies to tell us what they need. Hunger increases our cognitive focus on food and, historically, ensures an increased likelihood of survival.

If society values thinness over many other necessities of life, hunger takes on a very different meaning. Hunger can feel like a nuisance, a weakness, a temptation or even a sign of loss of control. People very focused on weight will attempt to find ways to tolerate, avoid or negate hunger without eating.

To an even greater degree, people with eating disorders seek any way to neglect and ignore hunger cues at all costs. As I have written many times in the blog, people with eating disorders eat what and when they are allowed by the illness, not according to hunger cues.

There have been many pharmacological and surgical attempts to mitigate hunger, but none of have been nearly as successful as the GLP-1 agonists. Thus far, this new class of medications can suppress hunger for long stretches of time leading to periods of undereating and weight loss without allowing our biology to override the medication with rebound hunger. The jury is out about long term effects, but these medications have introduced a new dimension of medical intervention into modulating hunger.

Although there are many ways our attitudes about hunger, food and weight will change in this new world, my concern in this post is about hunger. The idea that hunger cues can no longer play a large role in daily life for many people is a monumental shift in daily functioning and in eating disorder recovery. Tolerating hunger and learning to read body cues have both been critical parts of eating disorder recovery. Many people may now choose medication over an essential part of recovery.

Just as concerning, children brought up in the world of GLP-1 agonists will believe hunger is a feeling that can be medicated away, not a physical sign that the body needs food.

Fear of hunger is very different from the ability to medicate hunger away. Is it safe to ignore signs of hunger? What are the risks of ignoring such a fundamental aspect of being human? That will be the basis of Part II in the next post.

Chronic Anorexia Vs. Terminal Anorexia

The recent article about Anorexia Nervosa in the New York Times informed its readers about the severe medical consequences of this illness. In fact, the article made the case that some people with Anorexia might do best with palliative care, perhaps even assisted suicide.

For a clinician who treats people with eating disorders, the article did not talk about anything new in the field but focused largely on the most extreme cases.

The two doctors the article highlighted work on the medical floor which treats the most acutely sick patients in the country, aptly names ACUTE. Doctors know to send the patients in need of highly skilled medical care for eating disorders to this ward. I have worked with them many times, and they are uniquely able to shepherd these patients to a medically stable place for residential treatment.

Accordingly, these doctors also see a larger percentage of the sickest patients, including some who are so chronically ill that they may either need care to help manage severe intractable symptoms and may not survive their hospitalization.

Clinicians in private practice also see patients this sick who may refuse to go to ACUTE or be ineligible due to insurance issues. Some of these patients also won’t survive their eating disorder.

Calling the illness these most severe patients have terminal Anorexia as opposed to chronic Anorexia is dangerous. Since the ACUTE doctors don’t follow the most ill patients with Anorexia long term, only during their weeks long hospitalization, they may not have appropriate perspective to coin a new diagnosis.

Some patients with chronic Anorexia do need management of their medical symptoms, without hope of recovery, and some are not able to survive. However, a number of patients I have seen who would have qualified for this new term not only survived but fully recovered, and a few of them went to ACUTE as well.

I’ll link an old post from this blog about Chronic Anorexia as a counterpoint to the article.

An article read by many people about the severity of Anorexia is useful for general knowledge and understanding about this illness. However, using the platform to expound on a new diagnosis without consulting doctors in the field is risky.

Any new direction in diagnosis and treatment needs to rely on a consensus of clinicians, not the opinions of a couple of knowledgeable doctors with a narrow lens on the field.