New Treatment Directions for Eating Disorders

The last post highlights a problem with eating disorder treatment: not listening to our patients. The field has been stuck in the same treatment paradigm for decades without much progress, yet there is little urgency to consider new ways to help patients. We still believe that eating disorders are largely volitional and emotional: getting to the root case will change behavior, medications can augment success and, when that doesn’t work, ship people off to a “higher level of care.”

Years of experience show this plan does not work for a significant number of patients. They often end up cycling in and out of treatment without much improvement, actually getting worse and more hopeless due to how ineffective treatment can be or just forgoing treatment altogether.

We as clinicians accept both a very long course of recovery and the unsubstantiated trope that eating disorders “never really go away.”

There is no codified treatment protocol for providers, no suggestions as to what kind of treatment to pursue or even what works. Trainees in various programs have limited education about eating disorders. The guidelines from professional organizations are vague and, more often, just superfluous.

Any changes in treatment in the past decade were driven by patients as a community discussing their experiences, largely on social media.

That’s the way I have learned most of the new things I have incorporated into my practice the last several years: the role of ADHD, autism, MCAS and other inflammatory disorders to name a few.

Patients bring me their concerns and explain their symptoms with the help of their online community. I gradually accumulate clinical data to use for treatment, review diagnoses I didn’t know or remember much about and begin to change course of treatment. These additions often enhance and sometimes even accelerate recovery.

Medical research cannot keep up with growing theories about illnesses, eating disorders included. Clinical fields often have their own biases about the patient population or the illnesses they treat. But these facts sideline what’s most important. Patients themselves just want to get better. And if they bring useful information to their provider, shouldn’t that person do what it takes for people to get better?

That last point may be the key. Medicine continues to change rapidly. Access to information online combined with AI offer a broad foundation of (mostly correct) data right away. Amidst these changes, maintaining a creative and thoughtful approach to diagnosis and treatment is harder than ever. Switching gears to see patients not just as someone to treat but as a collaborator in diagnosis is a challenging transition for clinicians. Yet this step is essential to improve eating disorders treatment.

ADHD is one shining example of an improvement in eating disorder care driven by patients. Others are on the precipice of having an equally powerful impact. I believe all providers in the field need to keep in mind that a static treatment plan is not the most effective one. There is a lot more we can do to help people get better, and sometimes patients themselves have some of the answers.

On the Struggle for Women with Eating Disorders to be Diagnosed with ADHD

Medical research and care has always been focused on the health of men, typically white men. This fact is based on reams of research over decades focused primarily on this cohort. Many seminal medical articles solely about men remain the foundation of treatment. Subsequent research in many specialties rely on the original research as a springboard for further exploration and growth.

Although there has been some change in this truth of medicine, it’s difficult to overcome decades of work built upon the well being of one cohort of our population. Women’s health is often either sidelined or reliant on insufficient data.

One great example is hormone replacement therapy (HRT) for women in menopause. Flawed studies that showed a higher incidence of cancer from HRT led to decades of misled doctors shying away from HRT. Finally, years later, the benefits and minimal risks of HRT are evident, and care for menopausal women has been transformed, but at the cost of many women’s well being.

Eating disorder treatment falls into the same category. Eating disorder patients are primarily women, and research has been limited in many ways. Treatment is often run by finance companies, and research into new, more effective treatment is either unhelpful or often irrelevant.

A recent change in eating disorder treatment is the frequent combination of eating disorders and Attention Deficit Hyperactivity Disorder (ADHD). The overlap of these two diagnoses turns out to be very common, and treating ADHD improves eating disorder treatment for many patients.

The driving force for this new revelation is women on social media sharing their experiences and gradually recognizing their common concerns. Clinical care has been slow to catch up with many providers still believing that a patient with an eating disorder who mentions ADHD is seeking risky medications rather than asking for help.

ADHD historically has been diagnosed largely in boys. Girls often are overlooked due to a lower incidence of hyperactivity which is a red flag for teachers to recommend an evaluation. Girls often get by in school and do well enough by finding ways to compensate for the challenges of ADHD in an academic environment.

These adult women with ADHD seeking help were often overlooked as children and now find that modern psychiatry is not prepared to help either. There is no valid way to assess ADHD in adult women. The standard testing is for children. Treatment guidelines for adults are not clear either.

This one example, among many, shows how medicine frequently fails women. At least for now, psychiatrists need to find ways to diagnose women with ADHD and start treatment and education.

In eating disorder treatment, diagnosing and managing ADHD will improve outcomes and recovery significantly. The inattention, racing thoughts and struggle to complete tasks are all often triggers for eating disorder behavior. Treating these symptoms can help someone find their way to recovery a lot more easily. As a field, the eating disorder treatment world will do better for their patients by recognizing that ADHD diagnosis and treatment are critical for success.

Recovery Amidst Our Collective GLP-1 Delusion

There is a fine line between glorifying thinness and eating disorders. At times that line is more clearly demarcated than others, and the process of recovery is easier in that cultural moment. When the line is blurry and even hard to see, getting better from an eating disorder is a lot harder.

We’re in one of those challenging moments now.

GLP-1’s have taken over our world. Everyone seems to justify trying them: large and small people, sick and well, diabetic and anorexic. The list goes on and on. Some people are just curious. Even the suspicion that the president is taking one made the news.

Many people, more likely those prescribed too much or inappropriately, don’t eat very much. They feel full quickly, snack instead of eat regular meals. Many lose weight rapidly, often too rapidly, and start to seem sicker the longer they use the shots.

Culture and medicine call these people “healthy.” All of a sudden, looking very thin has become too common in some communities. Instead of calling out this behavior as a dangerous trend anyone can see easily, the mantra is that eating a lot of protein will solve the problem, all to justify getting too thin and sick.

The nonsensical approach to the GLP phenomenon is confusing at best and frightening at worst. Starving and losing a lot of weight is the new goal. Where are the sane minds pointing out the insanity of this collective state of mind?

Add into this morass those in the midst of eating disorder recovery, people struggling each day to complete a meal plan, to adjust to changing body shape and to manage the emotional maelstrom that comes with the process. How do these people ignore the shift around them towards rapid, dangerous weight loss? How can they forge ahead to get better?

The underlying philosophy of weight loss at all costs isn’t new. We just have a new, powerful tool to make it happen, at least for now, one that medicine treats as if it is the second coming.

People in recovery need to use all the tools at their disposal to move forward. They know the pain of an eating disorder, how bad they feel physically and emotionally. They know how personal and professional goals go by the wayside when they are sick. They know how they get trapped and have no joy in their lives. They know, deep down, that no pleasure from weight loss is worth it. Even if the world is playing with fire with the GLP-1’s, they know that recovery gives them a chance to really live.

I don’t have a new or more convincing argument about why it’s important to recover. The thought process remains the same no matter what newfangled medication or weight loss program emerges. The focus on living well has to outweigh the desire for thinness. That’s the way this process works.