--Adolescent program parent
The concept of recovery and eating disorders is often a complicated and confusing discussion. Use of the word "recovery" can mean many things to different people. Sometimes by recovery we mean that weight has been restored. Sometimes we mean that all behaviors have ceased. Sometimes we mean that all eating disordered thoughts are gone. Sometimes it means our triggers no longer trigger us and sometimes it means that our lives are back to normal, whatever normal may mean for each of us. So when we talk about recovery, we need to know what we mean, what is reasonable to expect, and how to understand that the process of recovery has many different stages.
It is reasonable to presume that a person's behaviors will stop and that weight will normalize to whatever it should be. At its most basic level, recovery should include both of these expectations. Without these changes, a person is still dealing with having an eating disorder on a daily basis. After weight has normalized and behaviors have ceased, the concept of recovery begins to change. The order of these changes will be different for different people. As discussed above, there will be multiple stages of change, including: how a person thinks, how they feel, how they spend their time, what their comfort level is, and how they get comfortable with their bodies and minds. In general, recovery should be thought of as a journey, not a destination. Eating disorder or not, all of us throughout our lives will be working hard to be as psychologically healthy as we can. No one ever reaches a perfect state of enlightenment, in the same way that no one with an eating disorder should expect that their thoughts and feelings will attain a perfect freedom from their disorder. But it is very possible for eating disorder thoughts and feelings to move far from the center of a person's life. Many individuals reach a state of comfort around triggers, develop a healthy relationship with food, and eventually feel comfortable inside their bodies and minds.
In her book, Gaining, which is one of our favorite books about recovery from an eating disorder, Aimee Liu quotes Dr. Sheila Reindl by stating "Recovery is like a big old house. The anorexic or the bulimic is always going to live there. People sometimes think, I can evict her, I can get rid of that. But you don't develop an eating disorder for no good reason. Its a profound experience. So how could you wipe out that whole piece of your history? I prefer to think of it this way. She was in charge of the kitchen, in charge of everything. Now she still gets to live there and she may still have some of those old fears and vulnerabilities, but she's got only one room in the house and has to make way for more and more occupants as time passes."
Next week: What is orthorexia?
Contributions by Sarah Emerman
Medication may be part of successful treatment for bulimia nervosa. In multiple studies, treatment with antidepressants has been shown to be moderately effective in reducing the binge/purge cycle of an individual with bulimia nervosa. Trials have shown that antidepressants are superior to placebos in diminishing overeating, decreasing self-induced vomiting, and increasing the sense of control that someone has over their eating. Other studies show the response for those with bulimia to be similar to the rate of response with depression. Since it takes approximately two weeks to observe changes in depression with medication, it is implied that within two weeks some benefit may be seen in those with bulimia as well. Large scale evaluation of the studies of bulimia suggest that high doses of fluoxetine, generally within the range of 60 mg a day, has been optimum for reduction of behaviors and improvement of sense of control. In general, the rate of response to antidepressant medications, in particular fluoxetine, has been shown to be approximately 50%. To date, no consistent predictors of response have been identified. That is, a level of depression prior to treatment does not predict how well these will work with bulimia, even though they may be indicated for depression.
In no situation should medication be used alone for bulimia. Studies demonstrating the effectiveness of medication are clear that all medications are secondary to primary treatment with Cognitive Behavioral Therapy or Dialectical Behavioral Therapy. As noted above, fluoxetine, a selective serotonin re-uptake inhibitor "SSRI", has been studied more often than other medications. Studies by Walsh et al. suggest that taking an SSRI while undergoing Cognitive Behavioral Therapy can result in a significant reduction of symptoms of bulimia (Walsh, Wilson, Loeb, Devlin, Pike, Roose, Fleiss, & Waternaux, 1997). Studies also tend to show that by three weeks of treatment with an SSRI at an appropriate dosage, patients who will respond to medication have already started to show a response. Therefore, the benefits of SSRI treatment should be quickly experienced.
Of some concern with medication and bulimia is the potential seizure inducing risk of Wellbutrin. Because both bulimia and Wellbutrin have been associated with seizures, in general the use of Wellburtin in patients who have bulimia presents significant risk. It is not fully clear whether this risk is theoretical or has been experienced by a significant number of patients with bulimia, as studies of this question are not available. Given the theoretical risk, we try to avoid this combination whenever possible. There is also a small literature on the use of stimulants in patients with bulimia. These remain case reports and we await more thorough studies on this question. Again, given the potential seizure risk of stimulants, they should be used with caution.
A side note needs to be made concerning Topamax, which has been suggested by some clinicians as being an effective treatment for bulimia. To date, studies have not shown Topamax to be superior to an SSRI. Topamax may be associated with paresthesia (tingling) and cognitive impairment. Although Topamax has been reported to have effects on weight, the literature does not support using Topamx for weight issues with bulimia.
Walsh, B. T., Wilson, G. T., Loeb, K. L., Devlin, M. J., Pike, K. M., Roose, S. P., Fleiss, J., &
Waternaux, C. (1997). Medication and psychotherapy in the treatment of bulimia nervosa.
The American Journal of Psychiatry, 154:4, 523 - 531.
Next week: What does it mean to be in recovery?
Contributions by Sarah Emerman
Pharmacotherapy (the use of medication) is in general only minimally helpful for patients with anorexia nervosa. There are no studies demonstrating that any medication leads to recovery from anorexia. Many medications have been tried, including Selective Serotonin Reuptake Inhibitors (Prozac, Zoloft, Celexa, Lexapro) lithium, marijuana, Clonidine, Reglan, Propulsid, and Naltrexone, but none have been shown to be effective. The atypical antipsychotic medications (Zyprexa, Seroquel, Risperdol, Abilify) have been utilized in several trials for anorexia. They have not been shown to result in recovery.
Although not successful in producing recovery, medications may be indicated as part of a broader treatment program for anorexia. In this context a broader treatment plan means that the level of care is an intensive outpatient or a day treatment program with the presence of a multidisciplinary team including a dietitian, psychiatrist, primary care physician, and therapist. A multidisciplinary treatment team must be involved any time medication is utilized since it should only be used as an adjunct to treatment.
Within this context, two groups of medication are sometimes helpful.
Of special note: the Selective Serotonin Reuptake Inhibitors (SSRIs) are often ineffective when someone is at a low body weight. At a low body weight a person has diminished protein synthesis, diminished neurotransmitters, and therefore diminished ability to benefit from these medications. One may also see increased toxicity at a low weight, including gastrointestinal side effects. There is some evidence, however, that SSRIs may help prevent relapse once weight is restored.
For more information on medications used in the treatment of eating disorders visit: http://www.something-fishy.org/doctors/medications.php
Next week: Medication and the Treatment of Bulimia Nervosa
By Dr. Jorey Friedman Beegun and Dr. Mark Warren
In Family Based Treatment (also known as the Maudsley method), parents play an active role in refeeding their child with the goal of restoring their child's weight to a range that is appropriate for their age, height and optimal medical and psychiatric functioning (as determined by a team of professionals and tailored specifically to the child). Once that has occurred, the parents gradually return control of eating back to the adolescent in a manner that stabilizes weight and behavior and allows for a focus on adolescent developmental issues that are often thrown off track by the illness.
Phase I of the Maudsley method in treating anorexia involves a shift of total control of eating from child to parents during which time the parents are responsible for making all choices surrounding food and re-feeding the adolescent. This first phase of treatment is critical because of need for the child to be gaining weight during a time in which their brain is malnourished and the fear of weight gain is acute. Given that many of the thoughts associated with anorexia nervosa are side effects of malnourishment itself, having an individual therapist or family member try to "convince" the adolescent to eat and gain weight is not successful and has no empirical support. What their brain needs is food and Phase I coaches the parent on providing their child the medicine (food) they need.
Phase II commences when a child has been successfully re-fed and parents believe that the child is ready to attempt to re-gain some control over their eating and food choices. Phase II extends from the very first collaborative moment around eating between the parents and child until the point where the child is able to successfully feed him or herself on a regular basis. This does not mean that the child will have no eating disordered thoughts, feelings, or body image issues as the time in which is takes for these to diminish or dissolve entirely is different for each child. However, the child's ability to tolerate and process these feelings is such that they can be working on eating independently in a gradual fashion. Thoughts, feelings, and body image can be successfully addressed in phase III when normal teenage issues move into the forefront.
Phase III begins when the adolescent is able to maintain appropriate body weight and restriction has stopped. The focus shifts to an exploration of how the eating disorder has impacted the formation of a healthy adolescent identity and works to help both the parents and adolescent get back on track in terms of supporting age-appropriate developmental tasks.
It is important to note that the there are differences between the phases in FBT for those struggling with Bulimia Nervosa and Eating Disorder, Not Otherwise Specified given that those adolescents are often weight-restored. The Maudsley Method is more collaborative with these diagnoses, the degree of which is clinically determined during the initial Maudsley sessions.
Contributions by Sarah Emerman
As we enter the new year, the new federal mental health parity legislation goes into effect. While this legislation is a landmark in many ways, at this time it does not guarantee that people who suffer from eating disorders will be able to access treatment without discrimination by insurance companies and state rules/regulations.
For all of us in the eating disorder community, a top priority must be full parity for eating disorder treatment in every state. At present time, Ohio limits mental health parity to seven diagnoses. It does not specify eating disorders as one of those diagnoses. It is a goal of CCED to make the legislature aware and to assist advocates, patients, family members, and friends of those with eating disorders to encourage the state of Ohio to acknowledge the biological basis of eating disorders, the effectiveness of evidenced based care, and the necessity for all insurance companies to provide parity coverage for eating disorder diagnoses. Please join us in this crucial step towards helping those with eating disorders achieve recovery and a fullness for their lives in this new year.
Check out the following websites to learn more about the legislation surrounding mental health parity and eating disorders:
Next week: What are the phases of Maudsley?
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