Increased Awareness of Eating Disorders has Changed the Process of an Initial Assessment

The last post reviewed elements of a thorough assessment for someone with an eating disorder. There are key pieces to this initial consultation that are necessary to create an appropriate treatment plan.

The first issue is that eating disorders are not a homogeneous set of illnesses. Underlying connected, and sometimes causal, conditions need attention as well. The increased awareness of eating disorders means many people are diagnosed without giving attention to other concerns. It’s easy to just decide the primary issue is an eating disorder without considering many more possibilities as well.

As a result, these days I am more likely to see someone diagnosed with an eating disorder whose main diagnosis is depression. In the past the opposite was much more likely to be true. The takeaway message is that diagnosing someone with an eating disorder without considering all other psychiatric issues is inadvisable and often counterproductive.

The second issue is that potential causes for eating disorder symptoms are not just psychiatric. Many medical conditions mimic eating disorders. Simply making the diagnosis and starting treatment often means people are getting help for a completely inappropriate condition. Many gastrointestinal diseases, ARFID and metabolic dysfunction are some of the most common alternate causes for eating disorder symptoms. However, there are many other options which need to be considered depending on a person’s specific symptoms and experience.

Trauma belongs in its own category of eating disorders. For most of these patients, the eating disorder symptoms are a means to cope with the symptoms of PTSD. The food behaviors can be calming, create order out of chaos and structure daily life. The only way to make change is to address the PTSD symptoms first to enable the person to begin to let go of the eating behaviors slowly and carefully. Traditional eating disorder treatment will be much too dysregulating. Severe PTSD appears to be more akin to a neurological disorder than psychiatric and needs very individualized care.

All of this information shows that people with eating disorder symptoms need a thorough initial assessment. The clinician needs to be able to sort through possible causes of the eating disorder, refer to other specialists if necessary and ensure the path of care is appropriate.

The increasing breadth of knowledge about eating disorders continues to expand treatment guidelines and opportunities while changing the guidelines for an assessment. These changes also demand a comprehensive first appointment before starting treatment.

The Needed Components of a Thorough Assessment of Eating Disorders and Implications for Treatment

The tendency to consider eating disorders as a homogeneous set of illnesses is misleading and frankly incorrect. They comprise a broad set of symptoms that are all include a focus on food, hunger and weight but typically manifest in very different ways.

Broad knowledge of how hunger, fullness, metabolism and weight are maintained by the body and mind is necessary to grapple with the healing process from an eating disorder. However, the treatment recommendations can vary greatly.

In this post I will explain some of the more general ways to differentiate eating disorders and elaborate more in upcoming posts.

Some eating disorder treatment is different based on the concomitant psychiatric diagnoses that need treatment with the eating disorder. The most common ones are Post Traumatic Stress Disorder, Obsessive Compulsive Disorder Disorder, Major Depressive Disorder and Attention Deficit Disorder.

The first key step is to differentiate whether the eating disorder or other disorders are primary and then to prioritize treatment for the eating disorder or other illness treatment accordingly. Sometimes treating the other disorder actually treats the eating disorder as well.

The second necessary step is to consider medical illnesses that might be a part of the eating disorder. These can include general inflammatory disorders, autoimmune disorders and metabolic disorders. Not enough is known about the connection between eating disorders and medical illnesses yet to lead to a clear path to recovery, but these new concepts for treatment are promising. Often searching for more general treatment for these symptoms, even with a clear diagnosis, can be very helpful in treating the eating disorder

Third, it’s important to consider the overall nature of the eating disorder symptoms in planning an approach for recovery. Cognitive Behavioral Therapy is extremely helpful for many eating disorders especially when binging is a primary symptom. Focusing on exploring and identifying emotions is often critical for people with more limited understanding of their emotions. For some, slow and steady work on changing eating patterns remains central to treatment for a longer period. The nature of types of therapy needs to match each patient’s needs.

A better understanding of eating disorders changes the formulation and course of treatment for people with eating disorders. Thoughtful consideration of all factors is necessary for any treatment to be effective. A thorough assessment and consultation will increase the chance of long-term benefit of any treatment.

The Transition of GLP-1 agonists from Weight Loss Drugs to Powerful Metabolic and Hormonal Medications

The introduction of GLP-1 agonists (Ozempic et al.) has completely changed the course of treating metabolic disorders. Even though the marketing of this new class of drugs has focused on weight loss—I believe, cynically, for increased profit, medications that correct metabolic hormonal dysfunction are the future of treating many illnesses, perhaps eating disorders included.

As of now, our knowledge about the broader effects GLP-1’s have on the hormonal system is very limited. Utilization of energy, hunger/fullness awareness, speed of digestion and normalization of blood sugar levels are all clear effects and match our current knowledge of the hormones affected.

But then why are so many people having other powerful effects? The list thus far includes decreased alcohol cravings, curbing compulsive behaviors, lowered systemic inflammation, broader regulation of other non-metabolic hormones and even augmentation in treating depression.

Clearly, there are broader implications of adjusting the gastrointestinal hormone levels which we know regulate metabolism. So the potential risks of taking these medications, and the risk of taking high doses simply to lose weight, are enormous and vastly unknown.

The collective fallacy about the GLP-1’s is that they are very safe and that we know the long-term effects. Through this lens, many people are taking these medications and our knowledge about them will grow quickly.

Over the last couple of years, many doctors have slowed down the dose increase greatly from the original suggestions of the pharmaceutical companies. For people on these drugs longer than three years, side effects appear to become more severe and sometimes lead to needed time off the medications, something that will be shocking for people taking them solely for weight loss. Sudden cessation of the drugs typically leads to weight gain.

The reason people need to stop the drugs is paralysis of the gastrointestinal system. Taking too high of a dose for too long can slow down the digestive system so much that it ceases to function normally. Stopping the drugs helps reverse this side effect, but the jury is out whether long-term use is possible again after suffering such severe side effects.

A few things about the GLP-1’s are becoming clearer. First, the broader effects of this class of medication are still unknown as is the systemic implications of altering metabolic hormonal levels. Second, it’s better to be a lot more careful with dosing and remain on as low a dose as possible. Third, the long-term use of these medications is in question. We don’t know enough yet to see if this is truly possible.

As the hysteria of the GLP-1’s dies down, medicine, and the culture at large, needs to respect the power of this new pharmaceutical step. Rather than kowtowing to the blatant disregard of our well being that weight loss marketing achieved, medicine can instead thoughtfully figure out how and when these medications are best used.

Relationships are the Foundation of Full Recovery

Therapy is central to the treatment of most psychiatric disorders but is even more so to the recovery of people with eating disorders. As trends in therapy focus more time on techniques and tools, the nature of the therapeutic relationship might get brushed aside. It’s crucial to make sure the relationship itself does not lose its place as a part of growth and healing.

Tools and techniques play a large role in eating disorder recovery as well. When someone has an urge to engage in any eating disorder behavior, the ability to turn to another action until that urge dissipates is necessary to make progress. That step is very hard and takes repetition and perseverance.

Similarly, eating regular meals regulate the gastrointestinal system to become accustomed to consistent food through the day. Using techniques to stay focused on eating through the day can be very helpful too. The physical cues for hunger and fullness ensue and give a person in recovery new ways to conceive of eating and thus reinforce the need and ability to continue new behaviors.

However, eating disorders also encroach on psychological and emotional development. At the start of the illness, eating disorder thoughts and behaviors replace all other possible ways to face emotions and reactions to daily life. The eating disorder is so powerful, so numbing, that there is no reason to even search for other ways to cope with being human. An eating disorder feels like a panacea to the travails of life while simultaneously extracting the joy, growth and connection that makes life meaningful.

In many different ways, relationships that are connected and true provide an antidote to the dullness of life with an eating disorder. For many people, the therapy relationship can be the first exposure to that sort of connection.

Any relationship that begins to compete with an eating disorder must, first and foremost, engage with the true sense of the person hidden behind the eating disorder. Only after one finds and connects with their true self can a person in recovery chart a course that escapes the eating disorder’s clutches fully. There has to be something more powerful and more important in a person’s life to consider letting go of a set of calming rules and structure. Invariably, personal connections make the biggest difference.

Recovery involves these two pieces—techniques and relationships—working together to form a new path in life. Once each person starts their new path, the directions splay in all new ways because recovery itself means becoming your own self and living your own journey.

The Financial Industry Interest in Eating Disorders

As I reviewed the last post, I neglected one way in which capitalist tendencies undermine the ability to find eating disorder treatment. The food, diet and health care industries collectively convince us to blame ourselves for any perceived shortcomings about food and body and then to purchase the wares to either remedy the problem or drown our sorrows. I neglected to mention the finance industry which cynically exploits mental illness for financial gain.

Many years ago, private equity companies bought up and expanded substance abuse treatment centers. Although the access to treatment centers improved, the intention of the industry growth was to create profitable enterprises to take advantage of health insurance benefits. Much of the data accumulated show how these clinics make unsubstantiated medical decisions to keep patients longer. The decision making process chose financial gain over patient well being.

The eating disorder treatment center model has started to look a lot like substance abuse treatment and became too tempting for the finance industry to ignore.

Residential treatment centers were, not long ago, places for intensive emotional work, soul searching and a safe place for people, primarily women, to find a path towards healing and recovery. Frequently, the programs were run by people who themselves had recovered from eating disorders and used their own personal experience combined with clinical knowledge to create centers with exceptional clinical care.

The rapid expansion of treatment programs by financial firms reeks of a quick grab for money. Although access to care had been a significant problem for years, opening many programs with poorly trained staff is not an improvement. The growth continues and the benefit from these programs decreases with each step while insurance money lines the private equity coffers. There isn’t enough focus on quality of care and too much focus on profit.

The limited benefit of residential programs makes the path towards recovery complicated. It’s harder to recommend residential programs than it used to be. Online outpatient programs have unclear value even though they do provide a needed service. Outpatient treatment is much easier to find but not sufficient for many people.

The problem of limited access has transformed into a struggle to find appropriate and educated providers. It is perhaps an improvement and also a sign of the times: medical care is increasingly driven by the patient, aka the consumer, who makes semi-educated decisions based on the limited information online. These are the overall trends in medical care but they are concerning for eating disorder treatment.

The Core Issue of Eating Disorders: Shame

A cornerstone to eating disorder treatment is addressing shame. For the majority of eating disorder patients, the rules, rigidity and behaviors of an eating disorder serve to cover up underlying, painful negative feelings about one self. Staying preoccupied and busy within the confines of the eating disorder hides the deepest feelings of shame about one’s body and oneself.

Beginning to uncover shame starts with an open and honest discussion of the eating disorder symptoms. Typically, secrecy surrounds the disorder not only because secrecy increases the power of the illness but also because it hides the shame. Speaking frankly about symptoms as part of the illness dispels the initial surface shame that’s paralyzing.

Eventually, eating disorder therapy shifts towards shame not only about body and self but often to other parts of one’s life. These causes are myriad and varied such as lack of emotional support, struggles to find a way through puberty, a dearth of individual recognition to create a sense of self or trauma.

The original causes will need different levels attention depending on the severity of the issue, but the severity does not change the nature of eating disorder treatment. Exposure of the illness and the feelings and experiences underneath can take away the engine that has driven the eating disorder for so long: shame.

We live in a world driven by shame in many ways, especially around body. There is little acceptance of bodies as they are and little admiration for all the types of bodies we as humans have. There is also little respect for the miraculous way our bodies can survive difficult times and thrive when given the chance. Our eyes look for criticisms and flaws, not for joy and gratitude.

The capitalist marketplace does not help. The food industry plies us with addictive foods; the fashion industry floods us with underweight models; the diet industry shames us to always feel fat and unworthy, and the medical industry lures us with magic weight loss drugs while also shaming us to change behaviors.

Our culture is designed to use shame to increase our desire to consume. Economic needs overcome personal well-being time and again.

It’s a large hurdle to overcome. The steps forward entail finding one’s self-esteem and confidence elsewhere. With personal well-being as a bulwark, each of us can try to ward off shame and live as our true selves.

The Power of Relational Therapy in Recovery

Therapy focused on tools and techniques, as described in the last post, is a primary mode of treatment at the present moment. Often, it feels as a therapist as if referrals to programmatic treatment such as DBT, CBT, EMDR, IFS et al. are the only appropriate and recommended options for care.

As the world becomes more scheduled and filled with content, our communal focus becomes consumption rather than having the space to create and learn.

Therapy seems to be going in the same direction. All of these targeted therapies have their place, but in the end we are all individual people with our own feelings and experiences. Any steps toward healing must include the space to grow and learn and create a truer sense of who we are and what matters to each one of us.

This type of therapy also has a name: relational or interpersonal therapy. The theory of this kind of work is that creating a safe and real therapeutic relationship in which the goal is to create space for the person to grow and reflect and learn about oneself all while experiencing care, kindness and affection. This therapy can lead to true healing not just of symptoms but of the individual.

For people with eating disorders, this therapy is immensely helpful. People with eating disorders typically have a very powerful negative voice or thoughts in their mind which criticizes and berates them at every turn. They may feign happiness and smile, but most people with eating disorders go through life with the burden of negative thoughts at all moments.

Recovery stops the eating behaviors and then needs to quiet and hopefully disempower these negative thoughts. The tools and techniques mentioned above can be useful for initial steps but won’t be enough to identify and strengthen a true sense of self.

Only a strong and true bond with unconditional support really makes a long-term difference. The therapeutic relationship needs to be real and to feel real so the person knows they have the freedom to grow and learn about themselves and still feel respected, cared for and loved.

I’m a big supporter of all the tools available that can help people manage anxiety, mood regulation and other concrete symptoms. However, I believe that relational therapy is the cornerstone of eating disorder recovery.