Children, Media and Eating Disorders, Part II

Most people can describe the gist of where their eating disorder came from, what they're missing in their life and what the eating disorder does for them, but it is an intellectual exercise and often only camouflage. Fundamentally, they don't really know what will help them get better. Focused and effective treatment of people with eating disorders needs to address the painful reality that their lives are run by the disorder without disrupting the core therapeutic relationship. This demands a few critical things: consistent but not judgmental attention to eating behaviors, unwavering compassion for the trials of enduring the illness, the capacity and desire to really listen, clear limits as to what therapy can do and what it can't and, most important, patience. When one of these ingredients is lacking, the patient will quickly recognize the deficiency and react, usually by getting angry or leaving the treatment. In a larger context, the therapist's job is to figure out which of these essential components means the most to the patient. In other words, what aspect of the relationship really helps slow down or even stop the symptoms.

For people whose symptoms do get better, there is a moment--or more likely a series of moments--when they finally see and feel what it is like to let someone, initially the therapist, into their lives. In that moment, a patient, who has only let herself exist in a small world hemmed in by a ruthless disorder, can finally see the freedom that exists for everyone else. What has felt like the calm sanctuary of the disorder transforms into the lonely prison she has occupied all these years. This is the opportunity for a patient to truly see what recovery looks and feels like, to finally arrive in treatment. It can be simultaneously terrifying to acknowledge how much time has been lost and miraculous to see the symptoms as relentless but for the first time not invulnerable. And this all happens with another person, the therapist. Allowing this real connection helps the patient realize what has happened to her, what is happening and how painful it all has been. The hidden suffering, even from the patient herself, becomes a moment of shared compassion for her struggle to try to survive the illness. At that point, when the intellectual exercise becomes grounded in the reality of living with an eating disorder and in the possibility of recovery, going back no longer feels like an option.

Patients often experience these moments as an immediate reliving of the entire course of the eating disorder but from a completely different point of view. This necessitates a rethinking of what the disorder has meant all these years. Most eating disorders begin between the ages of twelve and twenty, but the time of onset has more to do with luck and opportunity--such as enough privacy to use symptoms or exposure to really learn how to do them--than anything else. The vulnerability to the illness begins much earlier, as I explained in the last post. For many people, by the time they have ridden the course from initial exposure through the powerful, painful high of the first years of the illness, they are trapped. What felt like a choice, although it never was, starts to feel like a life sentence. The main delusion of an eating disorder, and what makes it so enticing, is that the person has mastered the world of food and weight and therefore is special, but the reality is quite the opposite: she is ill and unable to truly live. By allowing the therapist in and facing this reality, the patient irreversibly shatters that delusion. Re-evaluating every moment of the entire eating disorder opens up a host of emotions.  It is a rude awakening from the blinding calmness the eating disorder creates and a personal challenge to find the resiliency to face a wholesale shift in identity and self-worth.

These moments of arrival perplex me more and more. As I explained in a recent post, it has been eye-opening to realize that women with eating disorders often seem less stricken by an illness then chosen by a set of core personality traits--ones well-suited to success--combined with the conflicting expectations of society. The near universality of these powerful moments in successful therapy has the same jarring effect on my understanding of eating disorders. The moments feel remarkably similar no matter how different the person or relationship. I feel like I have witnessed the shattering of the shared delusion so many times, but how can they all feel the same? The essence of psychotherapy reinforces that all people and therapies are different, and so the sameness of these moments becomes all the more striking and has brought me to consider that the derailed development of identity and self-worth, especially in children, may be the missing link. The realizations occur when success within the eating disorder stops being synonymous with self-worth. But this means that the patient's identity must have been intertwined with food and weight long ago, well before the eating disorder started. Similarly, perhaps no true self-understanding ever started to develop, and these moments in therapy may be the first ones--no matter the age of the patient--of recognition of her own identity and value in the world.

With this foundation, these moments of arrival appear to be the formative experiences of learning to know oneself--something the influence of media has largely replaced in a child's process of growing up. If the messages and influence of the media are inescapable, then the goal is not to fight back as much as to offer viable alternatives: a way out for the young girls who see no other solution than to build an identity around food and weight. It also explains why these moments in therapy are so similar. Each moment represents a collective experience of helplessness and frustration: if living through an eating disorder--the preferred lifestyle of the times--does not work, what else is there? Living through food and weight seemed like the only way to make sense of it all.

These women have practically become the casualties of a lost art of parenting: creating hope and opportunity and individuality in kids in lieu of the current message of striving and conforming to a meaningless norm. What other value do women have in our society? Where can kids, especially girls, find role models who believe in a different kind of self-worth? What is there to strive for when the media influences our every thought and feeling? This brings the post full circle. When I wrote above about what a therapist needs to do to create an environment to promote successful therapy, I also described what children need to avoid this exact pitfall. When I suggested the therapist needs to search for what aspect of the relationship alleviates the eating disorder symptoms, I also described what children need from parents, friends and the world around them to find their own identity and their own voice and not succumb to the reductive appeal of the world of the media.

Next post, I will try to expand on how to apply the critical aspects of successful therapy to parenting about food, weight and the media.

Children, Media and Eating Disorders, Part I

The media's message has invaded the home and family as much as every other facet of our society, and there are many obvious reasons why. As a business opportunity, children represent a valuable advertising target if only because of their potential lifetime brand loyalty and penchant for browbeating parents into spending money. Millions of young souls are the tabula rasa of a media culture--a social movement masquerading as entertainment--primed to usurp parents' rightful authority and shape a directionless generation all too prepared to feel inadequate and fat, fat, fat. And why not? Kids have no idea where to look for guidance and identity, and the media can't do enough satisfy its own hunger for power and influence in the marketplace and for growth at any cost. And who's going to protect them anyway? Regulatory agencies or big business? Several previous posts make it clear that the answer is no. Parents? Themselves?

For parents raised on the splendor of icons like Tony the Tiger and "Trix are for Kids," media, advertising and TV used to mean something very different. It felt like sitting on the edge of your seat as a whole new world of promise came into view. As MTV and Star Wars dominated an ever-growing portion of the national psyche, kids placed their aspirations for a better world into media and entertainment. No one thought the media would renege on its unspoken promise and betray the national trust. Back then, the afternoon special starring a bulimic teenager seemed like a public service message about the rise of eating disorders, not the harbinger of a national identity crisis on the horizon. This was a time when the media knew its social responsibility to culture and society, when media celebrity meant being a role model to a new generation and MTV really did think it was changing the world. It's not that the media is less powerful--although that influence is no longer the purview of a handful of venerable institutions--but that the onus of building a better world has morphed into the need for immediate impact. When the goal is numbers and influence, nobody cares anymore what happens to the individuals who consume the media. Far from the heady but seemingly innocuous years of media forging a new frontier, now everyone is a consumer charged with protecting themselves. And with parents still awash in the old media ethic, that leaves children even more vulnerable to this brave, unforgiving, new world.

With no one protecting kids from media influence, it might be worth reviewing some child psychology to understand what the media uses to exploit children’s vulnerabilities.  The development of self-worth and identity goes through several stages, but one thing remains fairly constant: an absolute belief that they are the center of the world. Perhaps becoming an adult means fully realizing how false this is.  For children this is not a character flaw--as many overwrought parents are wont to believe--but an interesting psychological reality of modern life. It doesn't mean children think they are all powerful or that the narcissism makes them king of the world. Instead, it is a temporary solution to understand confusing events around them. Children understand the facts of the world long before they have emotional comprehension or a sense of personal identity. When kids don't have the tools to take something in, they almost magically believe they caused the events around them to happen and confuse their emotions with personal responsibility. Think of a child witnessing parents arguing. All kids think that they did something to cause the fight to happen: the emotions and context are too confusing. An adult would react emotionally but see that confusing feelings cannot cause something to happen. But that's much too sophisticated for a children, even for adolescents. And there is no amount of reasoning that would help a child to believe otherwise: call it the shared delusion of childhood. This means that, for a critical period of their lives, children determine their place in the world, i.e.  their identity and self-worth, exclusively from the world around them. If that world is predominantly peaceful and pleasant, the child has little to worry about. The more a child's life is complicated, confusing or worse, the development of that self-worth is marred by, for lack of a better term, "badness." Parenting manuals have distorted this fact of development into a backlash against discipline. Children still need rules and consequences and lots of them, but they also need consistency and praise. They need to hear through words and action regular reinforcement of their value and place in the world. By action, I mean the way parents, family and friends live their lives. Emotional maturity will follow.

With this background, it's easier to see why many children are at risk. Some kids will have the support system of family, friends and school that insulates them enough from the media to develop identity and self-worth influenced but not dominated by the culture of thinness. But what about the kids who have instability at home or live in a community consumed with thinness or take in too much "badness" in their lives or even just have parents who are unaware of the power of the media? For the vulnerable kids--not a small minority--this social movement becomes not just a culture but a cult that reels a large group of children into its fold. The appeal of a set of rules to define identity, a definitive moral code of food and weight to separate good from bad and an obsessive mantra that blocks out the confusing emotions of childhood and adolescence is just too satisfying to pass up. Add in parents themselves focused on media and thinness as a way of life and peers already drinking the Kool Aid and it's easy to see why the society as a whole has a tough time seeing the way to create a healthy, positive self-image in kids these days. An epidemic of eating disorders is hard enough to imagine, but what about the media culture as a rite of passage, or worse a method of raising the next generation? A discussion of some options to counter these real possibilities will be the topic of the next post.

The Media, Eating Disorders and Self-Worth

It's not enough to create the life you want unless you have the body to match. That's the adage most people live by in our society. Starvation, dieting and weight loss dominate a large swath of the mental time and energy of our daily lives. Even the most productive and successful people usually have a running food loop in their mind. To explore why maladaptive eating is so highly valued, it makes the most sense to understand what other values have slowly become worthless in recent decades. The daily pleasure of eating and the community of food has declined in importance, unless the food industry is your career. Youth and perceived immortality routinely trump the value of experience and knowledge. Any worthwhile political or social movement buckles under the weight of the media's choice of the news du jour. The substance and dialogue of our collective narrative are largely devoid of meaningful content in favor of celebrity gossip or diet tips. Even the more serious news reporting often emphasizes the need for lighter matters to shield us from the real concerns in the world. There is little focus on the meaning of our lives as an individual or as a whole. It is unclear whether there is inherent value in having an opinion, a voice or a community anymore or if they are just a means to an end. So the mastery of food and weight represents the apogee of personal identity almost by default. It's either a place holder while we wait for something of true significance to shape our self-image or a prolonged drug of the masses that lulls us into perpetual slumber.

If this were only the newest communal vice, maybe we could all just chuckle and move on, but there seems to be something insidious and more deeply disturbing underneath. The history of psychiatry reveals a series of psychosomatic illnesses which have primarily affected women--fainting spells and hysteria as the two most notable examples. These diagnoses were social constructs to pathologize, contain and, presumably, treat overwrought women who had no alternate emotional outlet in that era. How is it now that eating disorders often pick out extremely bright, driven and talented women and render them impotent? The media suggests that these illnesses are just a luxury of the well-off--just watch an episode of "Gossip Girl"--with nothing better to do than obsess about their weight and manipulate their food. Yet, across socioeconomic and ethnic groups, the personality traits that self-select for eating disorders suggest otherwise. Perfectionistic, diligent, hard-working. Self-sacrificing, empathic, engaging. Funny, self-deprecating, quick-witted. And always remarkably unaware of their strengths and talents.  Working with these women often feels like going to the hall of mirrors at an amusement park. No matter how much I reflect back the person that I see and know, all they can see is a distorted self-image. In the post-feminist world of supposed opportunity, these women seem primed to thrive and take advantage of what life has to offer. Yet, in the forty years since the feminist movement opened those doors, the incidence of eating disorders has skyrocketed. It feels too pat to imagine this is a coincidence. Has the influence of the media helped an entire society find a new way to contain and manage capable women in the useless pursuit of dieting and thinness? Eating disorders do seem like the current iteration of silencing women with psychopathology.

This is another instance where social phenomena and clinical acumen overlap. Effective treatment needs to undo the pervasive influence of media as much as the emotional and psychological cause of the disorder. That doesn't mean discussing the pros and cons of Us magazine. It does mean reassessing what gives value to a smart, capable woman in our society. Or what are the realistic goals a driven woman can aspire to. Or what it means to engage in the world without the constant fear and anticipation of personal judgment or sexual leering. Addressing these issues means directly questioning the world the media has shaped. Although that's a start, it's naive to think it's enough since we don't live in a bubble. Coming to terms with one's own place and value in the world will also mean questioning family, colleagues and peers: the immediate world around each of us. Patients who fully recover don't just stop their behaviors. Many people may eat relatively normally but still view food and weight as the most important part of their identity. Treatment that works has to help the patient recover her identity both personally and within her community. She needs to see herself outside of the hall of mirrors but also know that her value may still be seen through the prism of the media by many around her. It takes motivation and strength to persist in real recovery while the world still swirls around thinness. Recovery demands that one always pushes back against the tide of the media and strives to show one's true value. While everyone else just wants to lose weight.

If recovery involves taking a moral and philosophical stand against the perceived norm, it follows that the media, pursuit of thinness and eating disorders may be the closest thing we have to a social movement right now. With all of the current press about an anti-obesity campaign that largely ignores the complicity of big business and lax regulatory agencies, how can our national starvation escape without a mention? Michelle Obama placed her spotlight on childhood obesity but put her pre-teen daughter on a diet? The message cannot be more clear. The inherent danger of a widespread social belief that thinness is best leaves children with no other way to see themselves. The media has invaded the home and parents have made it acceptable to inculcuate children in this world view. And everyone just looks the other way. This will be the topic of the next post.

Media, Food and Weight-Overview

The media is meant to seem like benign, light entertainment to fill our days. But the magnitude of its influence on our lives is as unavoidable as it is insidious, especially when it comes to food, dieting and body image. It's not just that all actresses and models are thin so we want to be thin too. The media assumes we all know that being thin is the key to fame, popularity and success. In fact, it is the only way. The media does not act as if it dictates the social norms but rather lulls us into a state of mindlessness. How could Lindsay Lohan's last arrest not be supremely important? And, of course, she's wildly successful anyway. Because she is thin. You'd be completely out of touch--or worse, hopelessly lost--to believe otherwise. But then the media is much more than fashion, TV and movies. It's a philosophy and a social movement, a world view and a political ideology, and even a ubiquitous educational tool that shapes the way we see the world. Denying the existence of the media is like being an atheist. It's a personal choice but that doesn't eliminate the media from the world any more than denying god eliminates religion.

The media, perhaps more than anything else, taps into our true wishes and desires through expertly crafted images and messages that fill a huge void in modern life. Deep down, we all know the media did get it right. That's why it's so hard to resist. And, like any entity wielding such enormous power, the exeuction of its influence is solely a matter of exploitation. Just think of it. At any moment, people are reading the same magazines and watching the same movies and therefore striving for the same goals and to be like the same people. The role models--once limited to family, friends and perhaps a neighbor or teacher--now are universal. As the arbiter of cultural norms and ideals, especially for those affected most, adolescents and young adults, the media tells us exactly what really matters. And an industry has followed to monetize every aspect of our infatuation and continue to spread the word.

On an individual level, the road to social acceptance and personal success is lined with diet tips, new food fads and one central message: lose weight! By providing an inherently irrelevant yet alluring solution to the fear and isolation bred into our society, this industry has discovered infinite ways to distract us from the aimlessness and lack of personal identity that--literally--embodies our youth. Each airbrushed picture of an actress or model offers up the culturally sanctioned ideal, which each subculture and community attempts to slavishly recreate by searching for its own Lindsay Lohan or Lady Gaga. It's not only that these icons are unattainable but that following their every move serves as a kind of acceptable addiction that fills the void while providing an ethical and moral standard to guide us through life. It may seem banal to equate dieting with a reason to live, but that's truly what has come to pass. In no way does the media have a conscience for our social welfare. No, it's looking for what gets the most airtime and what sells. Thinner is better; starving is right; no weight is ever low enough; no diet is ever too radical; lose ten pounds and life will be perfect. 

The current and growing backlash against the media campaigns to normalize food and weight. But we can't all go back to a time when weight and food choice didn't dictate your place in the social hierarchy. A public health initiative to promote healthful eating only shows these young men and women how the establishment is hopelessly out of touch. People that age feel invincible and immortal. They are not cowed by long-term health consequences. Their fears are deeply rooted in finding an identity, somewhere they belong. The media taps into this longing with a quick, simple and supposedly easy solution. The old ads educating about the effects of smoking or drugs--and now about healthful eating--make sense to the middle-aged person in charge but don't touch an adolescent. "Lose ten pounds in a week. Look great for the summer!" or "Eat right. Get your fruits and vegetables every day. Healthy eating for a healthy life!" The only people who hear the latter message turn healthy eating into an identity of its own: orthorexia. For young women especially, the post-feminist era leaves too many choices, few realistic life paths and a paucity of successful and happy role models. But to control food, appetite and weight opens hidden doors in every part of life. Other women are impressed or envious. Men pay much more attention. People are willing to offer new opportunities, both professional and personal. Sadly, being thin, often at any cost, is transformative.

So eating less and losing weight do solve the problem, at least in the moment. A day spent not eating is a day lived well. Accomplishment for the day: 1000 calories, check. Your actions and your body do represent who you are. Your thoughts and feelings are extraneous--expendable items of daily life to be ignored or, when they break through, medicated away. Like it or not, this has become the norm for a generation raised on technology, quick and easy communication and domination of media in culture. Having some version of an eating disorder is a lifestyle, for many a choice, an identity and maybe even a career. It is a stamp of approval, the entrance into a coveted world of control inspiring envy in your peers. In many social circles, the misfit is the one who hasn't been on a diet, intentionally thrown up or taken diet pills. The young woman who orders chocolate cake for dessert when out with her friends inspires a world of gossip. Unless the whole group decided to have a sanctioned binge together. Because there is no viable alternative, an entire generation has turned to the media to answer many questions about life. And this is the result.    

As adolescence stretches past college to age 23, 25 or even 30, the media extends its scope even to young adults having children of their own. One generation passes this misguided sense of self on to the next like the secret family recipe or grandma's heirloom necklace or an inherited predisposition for diabetes. As the older generation fights the food industry and agribusiness, does anyone really think twenty-somethings are clamoring for organic produce and humanely-raised chickens? No, they're too busy throwing up the apple pie, Luna bar or handful of grapes. Something--an idea, social movement, national crisis--would have to replace the coveted role the media now plays in society. How else could the younger generation navigate the growing complexities of the interconnected, homogeneous world of the masses? How else to avoid the fate of just becoming a number? Where else can one find identity other than hitting the goal on the scale?

This introduction is meant to lay out the reality of food and weight in a media-centered world. I want to break this discussion down more specifically into a few components that focus more on the implications for the future. First, what does this mean for the value of eating disorders and disordered eating in our society? Second, how does the media politicize a world of thinness as a life goal? Third, has the media found a way to embed weight and food as something passed on to the next generation? Stay tuned. 

Hope

By the time most people with eating disorders seek treatment, they have little hope their lives can really change. The symptoms and disordered thoughts are relentless and, without any perspective, it feels impossible to imagine seeing the world any other way. The impetus to seek help comes instead from either external pressure or internal desperation. So much of what I have written about recovery boils down to maintaining hope. The daily battle of questioning the eating disordered thoughts, trying to eat and engaging with the world is exhausting. Without a sense of purpose or direction, the emotional pain feels pointless. All too often, the hope dies and the treatment along with it. Dropout rates are notoriously high, so much so that just continuing therapy is a predictor of improved outcome. Circling back to hope as a touchstone--a benchmark of progress--is one of the therapist's primary responsibilities, at least until the patient feels ready to share this duty too.

Living with an eating disorder means being grounded solely in the present. The past and future are irrelevant: the thoughts about food and weight in the moment are all that matter. Any decision either follows or breaks the rules of the eating disorder. It is a success or a failure. By definition, this sense of immediacy cannot coexist with perspective--an ability to step out of the moment and see the bigger picture. And perspective is a necessary component of hope. Without that psychological and emotional distance, any progress or change gets buried under an ever-present sense of inadequacy and shame. But the immediacy that makes the eating disorder powerful is also what makes it safe. Lack of perspective means lack of an identity separate from the eating disorder and that feels special, as if the person has life figured out, as if she a free pass from the daily struggles everyone else has to deal with. Perspective means starting to disentangle the patient's own identity from the eating disorder. Even acknowledging this is a possibility has far-reaching consequences. It implies that a different path may lie on the horizon. I have mentioned several ways to gain perspective in previous posts: food journals, medical effects of eating disorders, regular review of progress and developing a meaningful therapeutic relationship. Each of these steps will cause fear and apprehension but also cultivate hope in a future of recovery.

With perspective comes a very different emotional understanding of the eating disorder. The thoughts that are so harsh, demeaning and critical remain powerful only when the patient is consumed by the urgency of the present moment. People with eating disorders are, by and large, compassionate when contemplating other people's struggles. Some distance from the eating disorder stirs up that same sense of compassion for their own plight. The conflict between these two internal reflections is a pivotal part of maintaining hope. Once the therapy touches upon compassion for oneself, distinct from pity or self-recrimination, progress becomes palpable. The therapist can regularly remind the patient of her own sense of compassion for others and the possibility of feeling that way for herself too. Hope springs from the gradual process of learning to see oneself with understanding instead of reproach.

The other important result of having perspective is how it shatters the idealization of recovery. Many patients view their own potential recovery through the black-and-white prism of the eating disorder: perfection or utter catastrophe. The fear of prolonged misery, even after starting to eat normally again, girds the patient from any sense of hope, compassion or change. With some distance from this narrow scope of the world, the prospect of recovery changes too. Life, with all of its messiness and complexity, becomes clearer and lets the patient off the hook from needing to attain perfection. As terrifying as things look from this vantage point, the therapist can help the patient learn to be grounded in this new reality and feel as if she can survive, mainly by emphasizing hope. The ability to even acknowledge a world of confusion and complexity is a phenomenal step forward. The latent desire to move away from the security of the eating disorder is the patient's own way of seeing hope for a different life.

Occasionally, a patient who has been a stalwart believer in the immediacy and identity of her eating disorder glimpses how the other half lives. After months of hearing me go on and on about perspective, hope and compassion, she will let slip a word or phrase that suggests she has been listening. It could be a side comment about the eating disorder as separate from her; or an acknowledgement that the treatment has affected her eating disorder; or a hint at the progress in recovery; or even a session with limited discussion of food and weight. At that moment, it is clear that something has shifted. Any one of these comments or omissions implies that the patient has begun to have some perspective from the eating disorder. More importantly, it shows she is ready to share the mantle of hope for recovery. Perhaps what appeared at first to be complete fantasy may indeed start to feel very real.

The next few posts will shift in a new direction. I will address the impact of media on the culture of thinness and strategies to cope with its broad influence on our lives.

Medical Complications of Bulimia

Unlike starving, the symptoms of bulimia--primarily binging, purging and laxative use--cause immediate harm to the body. No patient can deny the physical toll these symptoms take. For many, the pain and weariness is a welcome relief from the emotional misery of the eating disorder. Although most patients are terribly afraid of the potential long-term damage, they are just as likely to ignore the risks of their behaviors and signs of deteriorating health. Patients often confuse the immediate physical effects of bulimia with the chronic medical complications and thereby underestimate the serious long term risks. Like with starvation, the body has to adapt to malnutrition and nutrient deficiencies, in this instance from lack of digestion and malabsorption. Unlike anorexia, which the body has an evolutionary inclination to weather, bulimic symptoms are a trauma to endure with a cascade of increasingly toxic effects. 

The gastrointestinal system--the part of the body most immediately affected--functions through peristalsis, the muscle contraction initiated by swallowing that pushes food through the system's entire length. Binging, purging and laxatives all disrupt this muscle contraction in quite similar ways. Binging expands the stomach and slows or even stops the muscle contractions temporarily, an effect even more pronounced after purging. Laxatives actively stimulate the colon leading to forceful and often painful diarrhea. These tramuatic shocks to the GI system lead to a period of slowed peristalsis with limited digestion and constipation. After recovery, peristalsis gradually resumes; however, prolonged symptoms can impair the body's ability to return to normal function. For instance, laxatives are addictive and chronic use makes it extremely difficult to have a bowel movement without them. Persistent binging may permanently slow digestion as the stomach is regularly overwhelmed with too much food or expects the contents to be purged. Consistent purging can lead to GI reflux (the food goes backwards into the esophagus) which is experienced as esophageal pain and bleeding.

One lingering effect of bulimic symptoms is electrolyte abnormalities, most notably a low blood potassium level. Purging, laxatives and diuretics all lead to excretion of this essential mineral and a gradual decline in the blood level. Life is considered untenable as the potassium level nears 3.0, but to many doctors' shock and dismay, bulimic patients have been known to walk around with levels under 2.0. For some people, the body adapts to the low level and manages to survive, for a time, but this is the most sudden and lethal complication of bulimia. Low potassium affects the heart rhythm and can precipitate cardiac arrest. Chronic low potassium also leads to kidney damage, and patients with bulimia even end up needing kidney transplants.

These complications are the most destructive, but the list of medical complications is long and equally mind-numbing as that for anorexia: hormonal abnormalities including infertility, slowed cognitive function, breakdown of dental enamel, persistent fluid retention and swelling. Most patients sit quietly waiting for the medical lecture to be over and are too afraid to see the full impact on their bodies. Two factors can help break through the powerful denial and help patients begin to process the risks of their behaviors: fear and timing.

The most common binge trigger is fear: fear of emotions, fear of new situations, fear of people and, ironically, fear of really being hurt by the eating disorder. The last fear is pervasive but hidden deeply beneath the need to binge to survive daily life. Using this fear to chastise the patient drives a wedge into the treatment: no one recovers when being consistently hammered with clinical facts. The therapist needs to broach any discussion of medical complications from a place of genuine compassion and caring. Too often families, friends and, sadly, clinicians place the blame on the patient and undo much of the progress. By trying to understand--and perhaps imagine experiencing--these fears, the therapist can make it safe for the patient to let down her guard. Feeling understood for the first time will allow her to express these feelings and acknowledge her desire to be well and to live fully.

A therapist needs to choose the right time to discuss the medical issues. Even with a sense of safety, a mistimed discussion often becomes an ignored lecture. If a patient is feeling vulnerable and confused but also safe and understood, the medical information can get through and help her face the reality of the eating disorder. This component of therapy relies heavily on the therapeutic relationship and on the therapist's ability to surmise that the patient is ready to trust the treatment enough to face her reality.

These two posts highlight how damaging and even lethal eating disorders are. Patients and therapists are often afraid to discuss these consequences and risk overwhelming the treatment. At the same time, any therapist who avoids this discussion is remiss. Engaging in this part of eating disorder treatment successfully sidesteps the patient's most valued protector, denial, and opens the door for another deeper question. How do you maintain hope during treatment for an eating disorder? Look for the next post.

Medical Complications of Anorexia

Most people with eating disorders feel that they are superhuman and impervious to the various medical complications that inevitably arise during the course of the illness. Books and articles present lengthy lists of the ways the body deteriorates from an eating disorder. I find the medical details numbing and completely disconnected from the reality of the disorder itself. I end up drifting when I try to absorb the information and I really want to remember it! If I cannot maintain focus, imagine how much a patient--deeply ambivalent about recovery--will actually remember. It makes much more sense to organize the information into a series of necessary steps the body takes in order to survive chronic starvation and vomiting rather than a laundry list of impersonal problems.

Let's start in this post with the effects of starvation. In the short run, eating less means the body uses more energy than it takes in. The body initially burns fat--the energy storage unit--to make up the extra needed calories. This line of reasoning is familiar as the natural result of a diet. Once the fat stores are depleted--a few months at best--the body adapts to survive the apparent famine in three interconnected ways: the use of protein as the new energy source, harboring limited resources for the most basic functions and a gradual slowing of metabolism.

Once the body begins to break down protein as an alternate energy source, survival becomes a zero sum game. Fat storage exists largely as a reserve to protect against lean times. Any use of protein as energy means using up this valuable and necessary resource. The body initially burns up skeletal muscle protein leading to atrophy and decreased strength. In time, however, any protein will do including cardiac muscle which leads to a weakening heart--one of the myriad ways eating disorders kill. Essentially, the body slowly eats away at itself to create as much energy as possible to survive, no matter the cost. However, the body was not created to survive through self-cannabalism. There are many deleterious effects, and one of the most severe is that protein metabolism leads to different waste products that need to be cleaned out of the bloodstream. The kidneys are damaged by the prolonged exposure to protein waste products, and even recovery will not always fully repair renal function. If this were the only adaptation to starvation, anorexia would kill people much more quickly so let's shift to what happens to metabolism.

During this prolonged famine, the body has to decide how to use its limited resources. For people with eating disorders, this concept is not evident because food feels like an unnecessary indulgence rather than a critical resource. Sometimes an analogy can emphasize why these circumstances are so dire and circumvent the denial of a patient. Consider a community experiencing severe drought. At first, people may decide to stop watering their lawns, a minor inconvenience. As the drought worsens, desperation sets in and the residents may agree to flush toilets less frequently or may limit each household to a maximum quantity of water per day. Finally, plumbing may be shut off completely so that individuals need to go to pick up their daily ration of water at a local well. Similarly, the body takes increasingly drastic steps for survival. For example, two common initial sacrifices the body makes during starvation are decreased peripheral circulation and trouble focusing--two functions not needed during a famine. The next step might be prolonged fatigue and dizziness, from not using energy to pump blood up to the head. More severe famine necessitates drastic changes: slowed heart rate and very limited mental function. The body may gradually eliminate all needs outside of the heart and lungs: the basic needs for minimal survival. Although the body will do anything to continue to live, the sacrifices are enormous.

The third way someone survives famine is a gradual, steady decrease in metabolism. The body, almost miraculously, adapts to become an extremely efficient machine. Each and every calorie of energy extracted from food is used as wisely and judiciously as possible. The gastrointestinal system slows down until it is almost paralyzed. In part this is atrophy from lack of use but also is to ensure extraction of every bit of energy from the limited food intake. Then the body slows down all of its functions in order to maximize the use of the energy taken in and minimize self-cannabilizing. There are countless examples. Liver function slows down leading to excess waste products in the bloodstream. Immunity is weakened and leads to increased susceptibility to infection. Heart rate slows down to levels commensurate with limited survival. The menstrual cycle stops because it isn't possible to be pregnant with limited resources and the menses itself wastes valuable resources.  Maintenance of healthy bones ceases. These adaptations severely limit what people with anorexia can do and often lead to irreversible damage.

This intuitive approach to the medical problems of anorexia is much harder for patients to dismiss. Humans have learned to adapt to famine in order to survive. Anorexia only exploits these genetic adaptations. It is unclear to me how effectively medical knowledge leads someone towards recovery, but I find that patients are more likely to process and remember the information presented in this way. The next post will describe the medical effects of binging, purging, and laxative and diuretic abuse.