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.