Eating disorders

Recognizing disease

By Abigail H. Natenshon, MA, LCSW, GCFP

Prerequisite to the treatment of eating disorders is recognizing their existence. Disease recognition is fraught with challenges.

Eating disorders are secretive diseases. As professionals, as doctors, therapists, nutritionists and educators, in looking for the possibility of an eating disorder, we are attempting to see what is not apparent.

Eating disorders are guarded and coveted by the individual who aspires to thinness, who finds through his/her tenacious grasp on the disease, a sense of power and control, of acceptance by peers, and appreciation by parents. Children with eating disorders rarely consider the syndrome to be a disease, and are not willing to risk having anyone take away from them what they consider to be their ticket to strength, beauty, popularity, and self-esteem. In some cases, parents who want their child to be thin, and who see that happiness and popularity are a function of physical appearance, view their eating disordered child's behavior as a sign of self-discipline and will power, and to be enviable and inspirational.

Signs to look for

Keeping in mind that eating disorders are diseases that are firmly rooted in both emotions and behaviors, look for signs in either or both spheres.

Behaviorally, you may see:

• weight change
• food quirks, such as eating a limited number of foods, in a specific order, at a specific time of day; vegetarianism may be a significant red flag, as is carrying one's own food to social events, or cutting food into tiny pieces, pushing it around the plate and picking at it rather than eating
• compulsive behaviors in other spheres of life aside from eating
• perfectionism and extremes in behaviors in other spheres of life
• bathroom behaviors, such as purging during and after meals, vomiting in the shower, etc.

Emotionally you may see:

• emotional inflexibility
• depression
• anxiety
• irritability
• social withdrawal
• difficulty concentrating and learning
• "feels" fat, even when thin

Professionals, beware! Disease recognition is a pivotal task for health professionals who are in a premier position to respond and help. Don't expect this problem to be neatly or voluntarily presented to you by your patient in your initial assessment, or even beyond. I suggest that you consider reframing within and for yourself what an eating disorder indicates about its host. Though self-destructive in nature, these diseases can be seen as a sign of the patient's will to survive and determination to so with "life quality". It takes great sacrifice and tenacity, self-discipline and intention, fear and anxiety to motivate these behaviors. That she will shield and protect the eating disorder and foster its continued existence can be seen as a sign of her will to live, to succeed, and to sustain herself in the best way that she can with the resources that are currently available to her. It is no wonder that she is ambivalent or resistant about confiding in you about its existence.

These diseases are often not detected in the psychiatrist's or psychotherapist's office. One of my patients began to work with me after spending seven years with a psychiatrist. She admitted to me that she purposefully chose not to tell her psychiatrist about her bulimia for fear he'd be "grossed out" and wouldn't want to work with her anymore, an attitude reflective of her tremendous shame. By the time she came to see me, this woman was purging up to 30 times a day.

Eating disorders are typically not detected in the pediatrician or internist's office, either. Eating disorders are hard to see, and physicians cannot rely on the patient to initiate discussion of them. Eating disorders will not show up in lab tests, (blood and urine) either, until the latter-most stages of disease.

There may be times when these diseases do present themselves and the doctor may be looking the other way or may be unable to decipher the clues being offered.

Consider the pediatrician treating a bulimic adolescent who prescribed diuretics in answer to the child's concern about avoiding "bloat during her period".

Consider the misinformed words of another doctor who told an excessive exerciser who had lost her period not to be concerned, as it is "not unusual for youngsters to have irregular periods till they are 21 years old". This statement is not true, but most unfortunately, by not responding to a blatant sign of disease, and by not following the lead presented by the patient, this doctor forfeited an ideal opportunity to make a life saving diagnosis.

In some instances, symptoms can literally scream out at professionals who choose not to notice and recognize them.

At a local hospital, an anorexic young woman was admitted to a general psychiatry unit for depression. Deeply concerned about her severely restrictive eating, her mother spoke to the head of the unit about her concern that her daughter was not eating any protein. This physician's response was, "Don't let that worry you. We'd all do better to eat less protein."

Might this doctor have had some personal issues of her own regarding food, blinding her to obvious call for help? Might she not have understood eating disorders and how they present? I think so. What is unfortunate is that this doctor was unaware of what she did not know.

In some instances, problems may not be screaming out, but gently tugging at your sleeve. Practitioners may do well to actively "play detective" getting a feel for a patient's personality structure, insinuating the likelihood of an eating disorder presence, and then actively investigating the possibility of its existence. Practitioners may need to "read between the lines," to look and to see, through understanding and instinct, if not through their eyes and ears.

Emilia, a well put together, highly functioning adult in her late twenties, came to me for treatment for depression. She described her past life at college, where she was overly controlled and controlling, obsessive, perfectionistic, and afraid to confront problems.

"You know," I said, "in listening to you, I wonder if you might have had eating issues when you were in college." Her response was immediate, shocked and grateful. "How did you know!?" she asked. "I never talk about those times." The next question out of my mouth could then be, "Do you ever revisit these behaviors now? May this become part of your goals for your treatment here?"

Remember that excessive exercise regimes may be an indicator of compulsivity, body image concerns and eating disorders. Activity disorders are a form of eating disorders. When activity and exercise becomes compulsive, when the exerciser has little choice but to engage in this activity at the risk of otherwise experiencing profound anxiety, if exercise takes on a life of its own, whether of not it feels good or does good for the exerciser, we are perceiving an activity disorder. Gymnasts, dancers and equestrians are much more prone to developing eating disorders than is the population at large. Ballet dancers are reported to be six times more likely to develop and eating disorder than non-dancers.

Keep in mind that eating disorders are behavioral problems that originate in emotions; at the same time, they are emotional problems that reside in a behaviors. The two cannot be separated. Where there is one, the other cannot be too far afield.

Don't be misled by the notion that an eating disorder will disappear on its own once a victim has dealt with the underlying emotional issues driving the disease. This is not the case. Eating disorder symptoms take on a life of their own in the manner of addictions. All aspects of these integrative diseases must be recognized, addressed and resolved at once for treatment to be effective.

Remember not to overlook the possibility that eating disorders may appear in your male patients as well. Men will have a greater tendency to binge and purge, which is more socially acceptable for males than to starve themselves of have their salad dressing "on the side." Males typically use steroids and excessive exercise to develop larger bodies, rather than smaller ones, as woman attempt to achieve.

Remember that weight is not the standard for diagnosis. Don't get hung up in this misconception! Thinness is not equivalent to having anorexia. Anorexia is not equivalent to being thin. Restoration of weight does not necessarily mark recovery, nor does starting to eat again, though these behaviors are prerequisite for recovery to occur. Weight gain can indicate the start of recovery when in conjunction with changing behaviors, thinking, and emotional versatility. Also keep in mind that it is a requirement for the malnourished body to be re-fed before it can fully benefit from psychotherapy.

Eating disorders are not solely about food or weight. They reside in every aspect of a personality and in the quality of emotional function. They are indicators of underlying problems that will need to be defined and resolved. In addition, they create problems in their own right simply by existing.

Eating disorder psychotherapy, counseling and medical modeling require a special use of the professional's self, special skill sets, and specialized knowledge.

1. The first challenge is that of recognizing disease, a topic that has been discussed at length. Recognition requires knowledge, the capacity to approximate and anticipate, commitment to the process in terms of taking initiative, and proactive intervention.

   In seeking to identify an eating disorder, it is important to become aware of how much evidence you need in order to know that an eating disorder exists, or that it is in the process of forming. The most astute and effective practitioner is the one who has the clearest vision of the potential for disease onset, having the least amount of information to go by.

2. The second greatest challenge is that of professional intervention. As described in depth in The challenges of effective intervention, one of the more unique elements associated with eating disorder intervention includes:

   The professional's use of self—The use of self with eating disorder treatment becomes uniquely challenging because the treating professional is required to deal with his or her own emotionally charged personal issues around food, eating, weight management and body image. The patient's issues could trigger a response in the unsuspecting professional that could hamper the quality of the treatment offered. Unless fully aware, cognizant and mindful of one's own poignant issues and concerns in these spheres, the professional is at risk succumb to an obstructed vision of the patient, the problem and his or her own role in managing these. Professionals are people, first, with all of humanity?s foibles and vulnerabilities. Professionals need not be immune to having problems of their own; nor should they presume to have all of the answers. What they do need to be is self- aware and versatile within themselves and in their responsiveness. The following are real life examples of professionals bringing personal issues to their work in a non-productive way.

   A patient worked with a therapist for over a year, yet chose not to discuss her bingeing/purging behaviors with her. When asked why, the patient explained that the therapist became weepy, "tearing up" whenever she spoke of her struggle with food.

   Another patient recovering from anorexia was struggling with the compulsion to over-exercise. Her concerned parents asked this young woman to discuss this problem with her therapist. Somewhat codependent herself and fearful of riling her patient, the therapist's need to appease and reassure took the place of attending to the unresolved issues at hand. She gave the patient the official go-ahead to continue exercising. Being unable to set limits and provide the necessary reality testing for her patient, this therapist missed a golden opportunity to help this patient grow and heal. How much more productive the dialogue could have been with "Tell me what you are doing, how is it different from before? What makes you think, or fear, that it might be excessive? Have you tried to alter these behaviors? What worked? What didn't work? What else might you try? How difficult is it for you to discuss this problem?"

3. A second major challenge for the professional is the unique requirement for the therapist to seek out and collaborate with professionals in other disciplines in the context of the treatment team—this team would hopefully be inclusive of parents and family. Typical objections of patients and parents to the idea of using the team approach to facilitate treatment are the prohibitive costs involved in working with multiple practitioners. Ironically, the efficacy of this collaboration makes it the most economically feasible alternative in the long run.

   Successful collaboration requires a team-based congruence of skill sets, of treatment philosophy, and of the "family system" bias. Inpatient clinics provide the most viable and workable milieu for professionals who operate under the same roof, as well as an efficacious source of support for patients. Outpatient treatment networks can be just as effective, however, when composed of competent collaborative professionals with like treatment philosophies, depth of treatment experience, and commitment to the healing process. Professionals sharing cases need to collaborate on a regular basis in order to guarantee an enhanced experience for the patient and for himself or herself.

   Professional treatment teams create the inevitable challenge for professionals of dealing with a random mix of personalities, with differences in treatment philosophies, and with the potential power plays that tend to occur among and between professional individuals with different treatment styles and approaches.

   Professionals should anticipate an overlap of function between the various disciplines, though taking heed when there might be excessiveness in this regard.

   Take for example the medical doctor who might attempt to micromanage the therapist's work, or the nutritionist whose focus might be too heavily weighted towards discussing the emotional aspects of food and eating to the exclusion of discussion about a food plan and the client's adherence to it.

   The wide range of professionals involved with eating disorder intervention requires a deep commitment on the part of each practitioner to the process, to the client, to the details of the case and to a successful outcome. These tasks require availability for unpaid cumulative time spent in conversation on the telephone, with parents of youngsters living at home, with out-oftown parents whose child is living away at school, with other collaborating professionals, etc. Team members need to communicate frequently and conscientiously with each other about patients they share, be it over lunch, on the phone, via fax, or email.

   One of the most important criteria for me in choosing to work together with a medical doctor on the treatment team is whether that doctor cares enough about the patient and the treatment process to call me to inquire about the patient's treatment progress prior to seeing the youngster, particularly if the visits are spaced far apart (every couple of months or so.)

4. The unique nature of the disease provides its own set of special challenges for the eating disorder professional.

   Eating disorders are integrative diseases that require the professional's integration of knowledge about various aspects of the eating disordered individual's persona, psyche and physiology. The helping professional, no matter what specific aspect of the disease he or she addresses, will affect the entire disease system and the entire individual. There must be therapeutic attention paid to the gestalt—to the body, the psyche, the emotions, and the social and cognitive functions. This attention needs to be ongoing and simultaneous.

   Eating disorders, because of their nature, impair the emotional faculties that would ordinarily allow a person to heal. The malnourished brain has little or no access to feelings, accurate cognition and self-perceptions.

   Problem solving, and most of all, the will or desire to recover, is impaired. The eating disordered individual's brain is further disabled by depression, anxiety, and a sense of hopelessness. Initially, the patient will be required to approximate healthful behaviors and responses, and eventually to grow into them through "leaps of faith" initiated, motivated, and guided by the strength of the therapist/patient connection.