Treatment Options
What's the first step toward treatment for anorexia?
I think it depends on the person's age. If he or she is a young, pre-puberty - puberty adolescent, who develops anorexia, the first thing that needs to be happening is the family members need to not be in denial because the longer it takes for the family members to come out of denial, the more entrenched their daughter is getting into her anorexia. Family members are in denial for a variety of reasons. They see her fun, they see her happy, her mood has improved because of the chemical changes that are going on, so her mood would have improved a whole lot. So as a result it takes a while for the family members to bring that person into treatment. The first steps are for family members or the person to begin to realize that what they are doing as a coping mechanism is not working.
What is the overall treatment program for anorexia?
First of all we have to develop a rapport with the client. We have to develop that connection, we have to restore them back to health, we have to make sure that all the medical needs are taken care of because we work very closely with a physician, a psychiatrist, a dietician. So it's a very multidimensional treatment. Our goal is to restore them back to health, and at the same time, have her to begin to identify why she needed to turn to the eating disorder as a coping mechanism. So we really talk a lot about what the underlying issues were. So when I talked about that pie chart earlier on in terms of these other predisposing factors, in treatment we teach her how to be able to identify what it is that predisposed her to developing an eating disorder and then begin to tackle each one of those and look at new way of coping with the stress in her life, or new ways of adapting to what the emerging challenges are that are showing up in her life.
What should I look for in an anorexia treatment provider?
I think it is very important first of all, there are lots of resources that are available for people to find treatment. One of the best resources that I often will tell people to go to is a website called edreferral.com. Alot of eating disorder professionals around the country are listed on that website. On that website she actually has buttons for "what should I be looking for in a treatment provider" because I think it is very, very important that a person can feel connected with the treatment provider they feel a sense of like that person knows what it is they are doing, that they are going to look after your child or your spouse or your partner or whoever it is you are bringing in for treatment. That they are knowledgeable in their field and they have dealt with difficult, complicated cases. That you feel heard, understood, validated and that they have time for you and they are not just doing this type of therapy for every person that comes along. In treatment you really want to be looking for, because even though the syndrome of Anorexia looks the same for everybody the predisposing factors and the different components are different for each person so the treatment really needs to be individually tailored to each person and working on their slice of the pie chart that is like the biggest and the most urgent to work on and then tackling it down from there.
What tests should be done when someone seeks treatment for anorexia?
When we have somebody that comes into treatment for their anorexia here, we do a very comprehensive - almost two and a half hours - assessment that we do of the person. In the assessment, we have some standardized questionnaires that they fill out. That's one part of it. Another part is an interview that we do. What we're asking about is their body image issues, what their nourishment is like, and what some of the factors were that were stressful as they were growing up. We do a very thorough history of the onset of the disorder and what behaviors they practice with their food or their exercise and things like that. Before a person gets admitted into our program, and the majority of programs are like this, we do a complete set of lab work, we do EKG panels, we do bone density tests, we do a hormone panel. We want to be looking at their hormone levels, we're looking at their bones, and we're doing a complete lab panel. Having said that, I can tell you that I could find somebody who could be 35 percent below their ideal body weight and their lab work will still turn out normal. That's how resilient our bodies can be under starvation. I'll often tell my parents that yes, we're getting the lab work done, but I guarantee you that even though your daughter's as thin as she is now, her lab work is going to come back normal. She could drop another 40 pounds and it would still come back normal. The lab work is never an indicator for diagnosis of anorexia, and I'll often tell people that. What we look at are these tests that we do and the different components of their personality.
Who are the professionals involved in the treatment of anorexia?
It's a very comprehensive team. We'll call them a multi-dimensional unit treatment team. They'll be a psychologist. There's a therapist, there's a dietician, there's an MD, a regular doctor, and typically there will be a psychiatrist. In my program I tend to be very holistically oriented. I have a nature-pathic doctor, I have an acupuncturist, and I have a yoga specialist as part of my team. Our team is very all encompassing in that we're dealing with a total body, mind, and all of the components. I don't necessarily want to go pumping a ton of medication into this girl for anxiety disorder. I may want us to do acupuncture first, and I may want us to do some yoga, and I may want us to do mindfulness. We'll do a bunch of those other kinds of things before we jump into a psychiatric evaluation right away.
What should I know about choosing a nutritionist or dietician?
The most important thing a family needs to do in choosing a nutritionist or dietician, is that they need to choose a nutritionist or dietician who specializes in anorexia.
What is the difference between inpatient and outpatient care for anorexia?
Well, there are lots of differences. We've got multiple levels of care. So when you have somebody that receives the diagnosis of an eating disorder, along with that will come, how severe is the eating disorder? So I could have somebody with anorexia that, maybe 50% below their ideal body weight, but they may just have to get off the eating disorder the last two months or three months or something like that. And what I'll want to do is do a lower level of care first. So we have a continuum of levels of care. We have outpatient psychotherapy, which could be once or twice a week, and see the dietician at the same time. Or we could have the next level of care, which is an intensive outpatient program, which could be three or four nights a week. Then the next level of care after that is a day treatment program, which could be from eight to four, five days a week. And then the next level after that is a residential program. And then the final level after that would be an acute hospitalization, like on a medical floor kind of a thing. So sometimes you could have an acute medical hospitalization before they have to step down to a residential level of care. Then they may do two or three months at a residential level of care, before they step down to an IOP level of care. So, depending on where they are with the eating disorder, how severe it is, we have guidelines. The American Psychiatric Association had created guidelines for what the level of treatment is, depending on where they are with their eating disorder. So we go according to those protocols.
How are the physical problems associated with anorexia treated?
The physical problems associated with anorexia do need to be treated. Typically, they are treated with re-feeding the person back to health. Re-feeding cannot happen very rapidly. We have a syndrome called re-feeding syndrome where if somebody with anorexia is given food very quickly, they can die of a heart attack right away because the body is not accustomed to receiving a lot of food. That is why it has to be an eating disorder specialist who works with ER anorexia. Sometimes I'll have patients who get hospitalized into an emergency room because they're having bradycardia or something like that. What the ER doctors will do is they will just pump all this fluid into them to get their pulse stabilized and everything like that. My patients will get really bloated, but what is happening for them is they're getting very high risk. Their heart has slowed down so much and their body is so malnourished that they can't take a lot of anything into their body. When they go into an inpatient program, for example, the way they are nourished back to health is a very gradual increase of calories until the body knows how to handle that. Over a course of six weeks they may be bumped up to 3600 calories or something like that. After you are at that level, calorically, it takes about six weeks before you might start to show one or two pounds weight gain. The amounts that they have to eat when they are in a residential program is usually huge amounts, because the body is so wasted.
How important is therapy in the treatment of anorexia?
It's super important. Without therapy, it's very difficult to treat anorexia. There's a method that's come about, that is a new thing in Europe, quite a bit. It's called the Maudsley Method. In the Maudsley Method there's this huge emphasis on getting the anorexic nourished back to health first, before you start psychotherapy. The thinking behind the method is while they are so malnourished, you really don't have the person that present, so how can psychotherapy really begin. The way we do the treatment, is we give a lot of supportive therapy, we encourage the parents, and we give a lot of support to the whole system at the outset. What we find is once the person does get nourished back to health, that's when we get into the meat of what has to be done.
Why is cognitive behavioral therapy the treatment of choice for anorexia?
The reason why a good solid eating disorder treatment program should have cognitive-behavioral therapy is because part of what occurs with eating disorders is distortion of facts. There's not only that distortion of body image, but there's really all-or-nothing thinking, there is catastrophizing, there are all these distortions in thinking processes that occur for people with eating disorders. So cognitive-behavioral therapy is a very systematic type of therapy that helps us teach the patients how to identify the distortions in their thinking, so therefore they can learn to correct their own distortions so they have a baseline of thinking that's more realistic.
What medications are used to treat anorexia?
A range of medications are used. What we do know in our field, with the research that we know, is when we have somebody very, very malnourished. Here, typically none of the medications really start to take effect on them. So, the medication only takes effect after the patient is beginning to eat and has got some food going into her system. So, most psychiatrists, even a lot of residential eating disorder in-patient programs, will not put somebody on medication until they know that some of the eating is coming under way. Because we're receiving all of the essential amino acids in the brain, and everything. And so, none of the medicines are going to work. So, some of the typical medicines will be Selective serotonin reuptake inhibitors (SSRIs), such as, Paxil, Effexor, Prozac, or Luvox. Those are some of the primary ones that people will be on. And, so, we use a lot of Selective serotonin reuptake inhibitors (SSRIs). And then, with eating disorders because the anxiety factor is a strong factor, too. We'll may have some medications for anxiety that may go along with the anti-depressant medication.
How long can I expect treatment for anorexia to take?
Typically it depends on the length of time the person has had the eating disorder for. What I usually say to my patients who come to the program is, if somebody has had an eating disorder, say, for about 6 months to a year, maybe two to three years of treatment can correct it. So, we're looking at a substantial length of time. So if you have somebody who has had an eating disorder for three to five years, they should count on remaining in therapy for at least 5 years to really get rid of the chunk of all of their thinking that has been affected by this eating disorder. So I tell family members to be very patient with the process; that what she latched onto is something that made her feel so good that it's going to take her some time before she'll unlatch onto it. And then systemically there's so many family changes that need to occur anyway, so we're doing the family changes, along with the ways in which she is trying to cope with any stresses that come up in her life. And once a person is completed with treatment, I will often alert them and their partners or spouses or family members that times of transition are going to be very stressful times for somebody with anorexia, because change is very disconcerting to somebody with anorexia. So like say for example they might have come to me when they were 12 or 13 and they got completely recovered like a year or two of treatment, they're fine and they've gone off, I'll tell the family, "When she goes into high school that's going to be a high risk time, when she's getting ready for college and she's doing college applications, that final year of high school is going to be a high risk time. The first year she's at college is going to be a high risk time, and if we go by all of those times and it doesn't pop back up again, then when she finishes college it's going to be a high risk time, or when she's getting married it's going to be a high risk time." So, times of transition is when I alert them, to just going in and doing a couple of check-in sessions or something like that so you don't start falling back on those behaviors again.
