Stopping Stimulant Use in Eating Disorder Recovery

The last complication to cover in the treatment of ADD and eating disorders is how and when to stop prescribing stimulants.

There are so many reasons people start taking stimulants: as an appetite suppressant, when given them by friends, for depression or for previously diagnosed ADD. So stopping the medications often take a complex, winding road.

First, if stimulants work for a clear ADD diagnosis then there is no reason to stop taking these medications. As explained in previous posts, the key is to be sure both diagnoses are treated and that any potential side effects are attended to.

In other situations, stopping stimulants is more nuanced. For people clearly abusing these medications, the best step is to stop them and work on addiction as part of the treatment. Since stimulants are easily accessible, treatment must include attention to addiction and cravings otherwise a prescription isn’t necessary to continue the medication use. The addiction can vary from severe abuse to relying on these medications as an eating disorder coping mechanism. 

In addition to focusing on addiction, it means focusing on the eating disorder symptoms as well. Without the physiological and psychological crutch these medications offer for appetite suppression and weight loss, patients become very scared of continuing eating disorder recovery without stimulants. So the craving is both an addiction and a fear related to the eating disorder. 

It’s necessary to monitor food carefully during this process and work on countering eating disorder myths about food and weight while processing that stopping stimulants is a necessary step in recovery. It’s enlightening to see how little these medications actually affect food and weight and how the psychological impact is a much larger component of their power.

Stimulant discontinuation can be a marker of significant progress in recovery. Realizing that the steps forward come from one’s internal change rather than the stopping a medication is eye opening. It reveals how recovery comes from within and reflects true steps towards self awareness rather than loss of the power of a medication. Stimulant discontinuation can be a marker for positive change.

How Indecisiveness can Derail Eating Disorder Recovery

A common symptom of ADD and some learning disorders is indecisiveness. For a number of reasons, the process of making decisions, even seemingly inconsequential ones, can be very difficult. The issue is not in the actual decision itself but instead the process of choosing one and committing to it.

Often therapists try to work through the internal emotional struggle around decision making and instead attribute the issue to perfectionism or ambivalence about recovery. More often, the difficulty is related to organization, processing and prioritizing.

Symptoms of ADD lead a person to get stuck on one task for too long and to struggle to prioritize tasks in a timely manner to be able to accomplish them. Medication and CBT (cognitive behavioral therapy) are very effective in managing many ADD symptoms.

The same can be said about decision making. The most important initial step is to recognize that making the decision is much more important than the actual decision that is made. If the goal is to assess the options, make a decision and move forward, it becomes clear that the focus of the learning process is to make the decision and not worry about which decision is correct. 

In eating disorder recovery, decision making is imperative. Patients who struggle to make decisions find choosing food to eat six times per day in their meal plan to be onerous. Often decisions become so difficult that it becomes easier to avoid the decisions and not eat. Despite the desire to recover, decision making can derail recovery.

For people in this situation, a few steps can make a big difference in success with eating.

First, a much more specific and clear meal plan makes a very big difference. That means a plan with exact times to eat and exact amounts of food to eat. By taking decision making out of the equation at first, the goal is simply to follow the plan. 

The transition to creating a new plan not set completely by the team needs to involve only a few decisions per day with a few options. The goal is to practice meal planning and recognize that making a decision matters and the actual decision is less critical.

The biggest worry is that the team mistakes difficulty making decisions with the lack of motivation to get well. This incorrect assessment can be very demoralizing and also can miss the actual obstacle to getting better.

The Muddy Waters between the Diagnoses of an Eating Disorder and ADD

Diagnosing and treating ADD for people with eating disorders is incredibly complicated. For the majority of these patients, they have not been diagnosed with ADD as children. The lack of a formal and reliable process to diagnose ADD in adults creates a seemingly impossible situation.

Eating disorder symptoms often include the most obvious diagnostic criteria of ADD: inattention, difficulty following through with tasks, poor memory and periods of hyper-focus. Food restriction, binging and purging can affect all of these cognitive skills. If someone firsts develops their eating disorder at a young age, then differentiating an eating disorder from ADD is challenging.

Also stimulants, as neuroenhancers, do have a cognitive impact on people who don’t have ADD. That’s why college students share these medications during the most difficult part of the semester. There are nuances between how these medications affect people with and without ADD as I have written about before. But even these criteria are not foolproof.

When eating disorder patients ask about the diagnosis of ADD, which happens with regularity, the psychiatrist is left with a difficult decision. Treating potential ADD symptoms will likely be somewhat beneficial for the patient who will be more productive and effective. Also the psychiatrist and treatment team would need to monitor eating symptoms to see if the medication affects following the meal plan.

Medical monitoring can also allow the psychiatrist to watch for any abuse of the medication and be sure the patient is not misusing it in any way. Stimulant abuse is a common symptom of an eating disorder but harder to identify if the patient is looking elsewhere for the medication rather than working with the team to take it. 

On the other hand, introducing these medications to eating disorder patients can intensify the desire to restrict and perhaps open the door to new behaviors, even precipitating initial thoughts of abuse. 

In the end, there are no easy answers when diagnosing ADD with eating disorder patients and in treating them with stimulants. A clinician needs to consider the best alternatives, monitor with caution and be willing to change course at any time.

Our collective shift towards using medications for personal gain and the acceptance of the ADD diagnosis already complicate how much people should be taking stimulants. Adding an eating disorder to the situation makes it only harder to navigate. 

And so the best alternative is to balance the possible diagnosis, severity of symptoms and risk/benefits of trying this class of medications. The stronger the trust between the patient and treatment team, the higher the likelihood of success.

The Nuances of Determining an ADD Diagnosis

Attention Deficit Disorder has a complicated history in recent decades in psychiatry. This diagnosis used to be considered almost exclusively in children and only for the most obvious cases, largely in boys with hyperactivity. As the clinical approach to this diagnosis has changed and matured, psychiatrists have to consider this diagnosis much more frequently for a variety of reasons. 

First, women often were overlooked and the diagnosis was either missed or instead misdiagnosed as depression, anxiety or laziness. Girls had hyperactivity less frequently and so their symptoms were not noticed often enough. Plus, the internal gender bias in previous generations prioritized girls’ academic success much less. 

Second, psychiatry now considers the diagnosis of ADD much more as a possibility when differentiating possible causes for poor concentration or academic/professional success. So adults who were not diagnosed as children discover ADD may be something they have struggled with for their entire and seek treatment.

Third, stimulants like Adderall and Ritalin, previously seen in a negative cultural light, are now on the border between a medication to treat ADD and a neuroenhancer which enables people to hyper-focus for periods of intense work.

Last, research into the diagnosis of ADD is primarily focused on children. There is no valid standardized testing to diagnose ADD in adults. Although testing can be done, it is far from definitive which leaves the ultimate diagnosis in the hands of the psychiatrist.

Thus, ADD represents a diagnosis that has shifted both in clinical and cultural norms in recent decades. Any psychiatrist is challenged to try to distinguish between the various reasons an adult may be asking to be evaluated for a disorder not easily or clearly diagnosed.

When an eating disorder is present as well, the muddied waters become almost too difficult to navigate. Since eating disorders can cause very similar symptoms to ADD, the process of a formal diagnosis is difficult if not impossible to ascertain.

The diagnosis is based on best guesses using a patient’s history and overall symptoms through childhood and adulthood. Sometimes a trial of a stimulant is the only way to differentiate cognitive deficits caused by an eating disorder from true ADD.

Due to these difficulties, many eating disorder patients end up taking stimulants long term. I’ll discuss how best to manage this complicated scenario in the next post.

Comorbid ADD with an Eating Disorder

The most common dilemma regarding an eating disorder and the diagnosis of ADD is either distinguishing between the two or deciding someone has both diagnoses. 

Without even thinking about risks of the medications and ulterior motives in attaining prescriptions of stimulants, the clinician needs to take any concerns with attention, organization and memory seriously.

The central issue is a simple question. Is the eating disorder itself causing the cognitive symptoms or is underlying ADD the culprit? Ultimately, both situations are extremely common, and the answer is not always obvious and often takes a long time to answer definitively.

If a patient’s eating disorder is dominant, then the next best step is to hold off on the diagnosis. All eating disorder symptoms (restricting, binging, purging, laxative abuse, over-exercising, etc.) can have a significant effect on cognitive function that can mimic ADD. In this situation, it’s best to keep open the possibility of this concurrent diagnosis and instead focus on recovery.

If a patient has been previously diagnosed with ADD using Neuropsychological testing, then the diagnosis is not in question. It may not be appropriate to use stimulants yet depending on the state of the eating disorder symptoms, but it’s also critical to state that these two diagnoses can exist together and may in fact be correlated.

If a patient has improved significantly from their eating disorder and continues to have symptoms that could be ADD, then it is imperative that the clinician consider this diagnosis.

One option is to do Neuropsychological testing, but these results are not as reliable in adults as in children and can be prohibitively expensive.

Another option is to start a trial of stimulants and to monitor both food and changes in attention carefully. Stimulants work quickly at the correct dose and also can be diagnostic. When effective, they can aid in emotional stability and eating disorder recovery.

Although the steps in considering and diagnosing ADD are fairly clear when stated objectively, the nuances of the actual diagnosis are often more cloudy. I’ll start to look into these complications in the next post.

Eating Disorders and ADD, Overview

One particularly thorny diagnostic conundrum when treating people with eating disorders is the overlap with attention deficit disorder.

This diagnosis is particularly complex for many reasons. First, it has been diagnosed much more readily in the last decade after being misdiagnosed or under-diagnosed for generations prior. Second, the diagnostic criteria are for children, and diagnosis in adults is controversial and lacks any clear standard for the clinician to follow. Third, it has become in a patient’s interest to seek this diagnosis for accommodations in school and for so called “neuroenhancers,” known clinically as stimulants like Adderall and Ritalin.

The confusing clinical territory and incidental personal gain make the diagnosis and treatment difficult for any clinician to navigate.

However, when treating people with eating disorders, another added wrinkle is that these medications also can cause appetite suppression and weight loss as side effects. This fact makes these prescriptions very appealing to this cohort of patients.

Even more confusing, the diagnosis of ADD in patients with eating disorders is clouded by the fact that poor nutrition, binging and purging can all cause cognitive side effects that mimic ADD. Thus, the diagnosis is almost impossible to determine in an adult with an eating disorder unless the ADD symptoms started first. 

The final piece of the puzzle is that for ADD is actually the primary diagnosis for a small number of patients with eating disorders. And for these patients, treating previously undiagnosed ADD actually cures the eating disorder. The eating disorder symptoms actually managed the overstimulation and inattention common with ADD. Once treated, these patients no longer need the eating disorder to cope. Although this group is very small, it does mean the clinician can’t rule out undiagnosed ADD for any eating disorder patient.

Due to the complex relationship between eating disorders and ADD, I will use the next several posts to delve further into these issues and cover the following topics:

1. The diagnosis of ADD in the context of an eating disorder
2. The use of stimulants for people with eating disorders
3. Risk of abuse of stimulants in people with eating disorders
4. Use of non-stimulant medications for people with eating disorders who have ADD
5. Stimulant use as a neuroenhancer or party drug
6. Taking patients in recovery off stimulants
7. Indecisiveness, a common symptom of ADD and it’s role in recovery

The Internal Struggle Between Illness and Recovery

How can it be that eating and being nourished are the ways to recover and that eating and weight change feels so bad?

For almost all illnesses, the process of getting better also feels better. People often gain strength, feel more hopeful and can think more about their future.

Eating disorder recovery rarely involves a sense of forward progress. Eating many times per day, each day, for one day after another feels painful at first.

The sense of loss of not being able to engage in eating disorder behaviors is akin to losing one’s fondest pleasure, most effective coping strategy and a sense of accomplishment. Eating disorder symptoms wreak havoc on people’s lives and simultaneously give structure and meaning to each and every day.

So the steps of recovery are always conflicting and painful, never straightforward and easy. The ambivalence of giving up a foundational part of one’s life and identity is a slow death, agonizing but necessary.

Other ways of coping with life don’t also cause sickness, weakness and even death. Living with eating disorders means a much smaller life with much less room for relationships, intimacy and fulfillment. Although if may feel like a safer life, it’s also a sick and sad one.

This means that recovery means not only the struggle to eat each day and fend off the urges to do eating disorder behavior, but also saying goodbye to a life and to a way of surviving. It means giving up something that feels like a part of your identity and who you are. It means deciding it is worth learning how to live a full life and not settle for a sick and small one.

People do Recover Fully from an Eating Disorder

The most pervasive myth about eating disorders is that they are chronic and never go away. This falsehood has become even more widespread through the pandemic as it has been repeated widely on social media.

When unpacked, the myth reveals fears and untruths about the role of eating disorders of our culture.

The centrality of diet culture means that dissatisfaction with weight and body are extremely common and even dominant in many communities. So the concept of restricting food, the desire to lose weight and the virtue of being thin feel like facts to many in our society. As a result, many people who don’t have eating disorders and never did have constant thoughts about food and body.

Second, even though eating disorders are so destructive and severe for many people, these illnesses are still idealized. Anorexia especially is often seen as a triumph for people who have been able to overcome hunger and “control” what they eat. The truth of these disorders is very different.

Last, the explosion of residential treatment centers has diluted the powerful message many smaller programs used to convey. Centers focus on short-term health and treatment but rarely explain and reinforce what full recovery looks like. Thus, the end result of treatment is a partial recovery without further education about how to get better.

The crux of an eating disorder is the pervasive thought process about food and body that leads to compulsive behaviors and actions. These symptoms stem from inconsistent, insufficient eating so the body does not get the steady nutrition it needs to function. Without that sustenance, eating disorder thoughts grow and thrive.

To fully recover, the patients need to follow a meal plan, eat meals and snacks in adequate amounts and spaced through the day for months at a time. The body and brain need to learn that regular, nourishing food will be the norm again. Once that pattern becomes consistent, eating disorder thoughts will fade as life intervenes and becomes the focus of each day.

When this happens over time people get well. This is the truth about recovery. The myths above reflect a lack of understanding of these illnesses and the overvaluing of thinness.

Although the path to recovery is simple, the process of doing so is very hard, if not counterintuitive. Eating disorders are defined by abnormal eating patterns. Getting better means eating normally. I’ll explain this paradox in the next post.

The Role of Residential Treatment in Recovery

It has long been assumed by patients new to eating disorder treatment that a successful stay in an eating disorder residential program is essentially a cure. The buildup to admission, the hard work in the program and the culture of “Rez” introduce the concept that treatment will help you not get better but be cured.

Nothing could be further from the truth.

Residential treatment has many benefits, and the enormous increase in the number of programs across the country in recent years has improved access for many people who otherwise wouldn’t have options for inpatient treatment.

Treatment offers a safe place to learn how to eat again, nourish one’s body consistently for weeks or months and learn the skills needed to tolerate full stomachs, digestion and weight changes. For many people these steps are extremely difficult on an outpatient basis.

But residential treatment is also a bubble, an escape from the daily challenges of life. Work, friends, family and relationships all take a backseat while people are away. They can focus exclusively on recovery and the small world in the program.

No amount of preparation in that bubble can replicate the experience of being back in the world again. Even the most successful people in residential will find the urges and desire to return to eating disorder symptoms powerful after they get home. Once they experience the intensity of their emotions about the different aspects of their lives, everyone will feel the pull to rely on these symptoms, which have been a central coping mechanism for many years. Using new ways to cope is very challenging and takes time, learning and persistence.

What will improve outcomes and recovery after “Rez?” It’s a theme I have discussed many times in this blog, and here are the three main takeaways.

First, residential is the first step in recovery and in some ways the easiest. Don’t be tricked into thinking otherwise.

Communication between the residential team and outpatient team is crucial so that the transition is as seamless as possible.

Last, eat the food. Following the meal plan no matter what leads to people really getting better. That means completing the food log, being open and honest about any symptoms and seeking help and support at every turn.

Residential treatment is a critical part of recovery for many people. The more everyone understands its place in recovery, the more people can be successful.

A Clinicians’ Responsibility in Social Media

Clinicians, coaches and recovered people explain recovery work, spread knowledge and information and promote themselves on various social media platforms. The explosion of eating disorders treatment centers, normalization of these illnesses and isolation of the pandemic created space for many different voices in the eating disorder treatment world that everyone could access easily throughout the pandemic.

What’s confusing about all these new voices is the unfiltered nature of the noise. Social media algorithms attempt to keep you on the platform. There is no way to filter all the information to spread informed, knowledgeable or even true ideas.

Many people caught in the eating disorder web on social media find themselves trapped and often convinced of the ideas presented to them over and over again. If the message is about recovery and the harm of eating disorders then that’s great. If the message is about identifying fat phobia and body positivity then that’s important too. But it’s equally likely the message will be diet focused or even pro eating disorder. Without any way to filter out the destructive or false messages, the risks of developing an eating disorder or relapse only escalate.

These concerns are pervasive effects of social media in our current culture from politics to health to the pandemic. However, the increased incidence of eating disorders in the last year and a half shed light on how dangerous this messaging is and how clinicians need to be aware of the risks.

Treatment, in all different forms, needs to incorporate a strategy to include the concerns around social media. And clinicians using social media to promote themselves need to be careful how and in what way they are seen. The lines have blurred between treatment professionals, coaches, influencers and social media stars. As much as possible, clinicians need to try to distinguish what they do and why it’s different.

The best way to support recovery in this world is to remember that self-promotion can’t be the main goal. Any social media presence for a clinician can include links to their own practice and treatment goals but also needs to be sure to point people towards real, proven information about eating disorders, treatment and recovery.

No matter how much our online presence melds with advertising and personal brand, every clinician needs to remember that treatment and helping others is the top priority.

The Role of Social Media in Eating Disorder Recovery

So many people with new eating disorders or relapses had nowhere to turn for help during the pandemic. Society shut down as we know it and access to any mental health care was severely curtailed. The eating disorder treatment world, like all health care, became instantaneously virtual with no warning and no plan. Assessment, treatment planning, residential care and outpatient treatment programs scrambled to adjust but left patients minimal options for true care.

The incidence of new eating disorders skyrocketed, but patients couldn’t find help. Clinicians had endless waitlists. Virtual programs struggled to function because eating with people in a safe setting is central to the effectiveness of treatment. Residential programs had trouble even staying open and accepting new people safely.

So many people stayed home, trapped by the coronavirus, trapped by their eating disorder, alone and scared.

Home as well, clinicians, coaches and recovered people looked for new ways to attempt to help. The plethora of Instagram dietitians, body positivity influencers and recovered people had already had an enormous impact on the vocabulary and approach to eating disorder treatment. That burgeoning world exploded during the pandemic and added TikTok as an equally powerful platform.

But the increased exposure to recovery oriented content came with the algorithms intended to push people, especially teenagers, towards posts that encourage extreme dieting, low self-esteem and thereby increased the risk of eating disorders. Research data presented to Congress this week by a former Facebook executive provides incontrovertible evidence about the destructive effects of Facebook and Instagram.

The lay of the land in the eating disorder treatment world has been forever changed.

These social media voices express a varied, powerful and resonant chorus about eating disorders, body image and recovery which all clinicians must now heed. The messages previously attributed to older media outlets are no longer easily avoidable but instead in our hands and on our screens all day long. Ignoring this new reality means missing the basic understanding of how eating disorders now exist in our culture.

Let’s hope that the experience accelerated by the pandemic and by the exposure of Facebook’s destructive business decisions help avoid an even larger uptick in eating disorders. As clinicians, we need to discuss social media as a realistic outlet to aid in recovery. Focusing on the ways to use content to encourage recovery, reinforce positive messages about body image and self-esteem and avoid triggering images and diet advice is crucial. It’s imperative for clinicians to work with this powerful tool and not demonize it or ignore it.

The next post will venture into trickier territory. What is the role of clinical work in the social media universe? Where are the boundaries between helping people get better and self-promotion?

The Triumph and Failure of Teletherapy for People with Eating Disorders

Virtual sessions, a growing trend in mental health treatment, has become the norm and frequently the only option for the past eighteen months. Video sessions had been a new direction gradually being tested and used in various settings, but the pandemic made them compulsory.

I had used virtual sessions for many years but only with long-standing patients and as part of an ongoing therapeutic relationship previously established in person. Seeing people exclusively on video was an entirely new endeavor.

Virtual treatment for eating disorders poses very specific issues not found when treating other psychiatric problems. First, for patients just starting treatment, it is much easier to hide symptoms and particularly shameful issues around their eating disorder. Second, working in person feels much more exposing for someone learning how to face the deeper shame connected with an eating disorder. And third, being in the same room with someone allows for a much more personal conversation about food, the most intimate topic anyone with an eating disorder can discuss.

However, video does have a couple of benefits, namely convenience, which makes it easier for some people to have an initial appointment, and safety since they will already be home after talking about an emotional issue and not have to navigate their way in public.

But the pandemic did not allow a gradual process to evaluate and improve teletherapy. Instead, clinicians and treatment programs dove in and found themselves often not ready or able to adapt.

The end result is decreased effectiveness of care. With the increased incidence of eating disorders and relapses during the pandemic, many people have remained ill with limited opportunity for treatment.

Since virtual therapy is so convenient, many therapists gave up their office space and some have no plans to return to in person treatment any time soon. If convenience begins to trump efficacy, eating disorder treatment may suffer further.

Two things need to happen. First there needs to be more data showing the effectiveness, or lack thereof, of virtual therapy. Second, clinicians and programs need to learn how to adapt virtual treatment in ways that improve overall care. Although the treatment continues to adapt on the fly, that slow improvement may not be enough to stem the tide of illness.

In the absence of in person treatment and due to the long waitlists for treatment programs, for many patients, especially those newly diagnosed, social media became an even more important part of the eating disorder treatment world during the pandemic. That will be the topic of the next post.

Eighteen Months Later

Eighteen Months Later

Posted 9/15/21

The incidence of eating disorders skyrocketed during the pandemic. New cases, relapses and severity of illness all worsened at a dizzying clip. Clinicians’ outpatient practices were all full. Treatment programs were virtual for a time and had endless waitlists. All outpatient treatment was virtual, and people languished at home.

Virtual treatment led to patients finding practitioners all over the country. Geography was no longer a barrier, and treatment varied accordingly since no one knew how to help people through a screen and had to learn on the fly.

The lack of a clear treatment path also meant patients looked to social media more than ever for help and advice. Instagram and TikTok became central to many people trying to find information and guidance about treatment and recovery.

Never has there been such an enormous change in the eating disorder treatment world. Even as clinicians trickle back into the office, it’s unclear what happens next. Are eating disorders a chronic, untreatable illness? A passing phase caused by the pandemic? A community to join during the most isolated months? An identity to cling to when life stopped?

The fallout from this extended transformation of eating disorders will ultimately lead to a sharp uptick in severe cases who had enormous difficulty getting help at the start of their illness. And the treatment community will need to piece together a way to salvage this treatment and help many of these patients find the path to get well.

After an eighteen month hiatus primarily caused by fear, a constant stream of people reaching out for help and weathering the worst of this terrifying time, I feel ready to embark on chronicling the ever-changing world of eating disorders and treatment.

The first posts will elaborate on the changes in eating disorder treatment and the challenges that lie ahead for those looking for recovery.