Robin Rosenberg on Treating Eating Disorders

Robin Rosenberg: There are people who engage in both types of behaviors. In DSM-IV, individuals who exhibit all the criteria for anorexia but who also binge and purge would be diagnosed as anorexia nervosa binge/purge type. So diagnostically, anorexia trumps bulimia, if you will. But that is just the DSM-IV; who knows what will happen in DSM-V?

RR: They appear to be, at least for a significant subset of people. So in terms of the research, when you look at people who have bulimia versus people who have anorexia, that is not necessarily a helpful distinction. Anorexia has, in DSM-IV, two subtypes. There is the traditional restricting type, which is the people who eat minimally, and then there is the form of anorexia where people are significantly underweight and may be amenorrheic [they have stopped menstruating], but they may also binge or eat without restricting, but then purge in some way, or use other compensatory behaviors. Those people are classified as anorexia binge/purge type, but in studies, those people have more in common with people who have bulimia than they do with anorexia restrictive type. Some of this is a bit of a diagnostic artifact, because it's the way that it has been defined in DSM-IV.

The most interesting thing about eating disorders in terms of classification issues is that it is not uncommon for people to move from one eating disorder to another over time.

RR: One of the things that is clear is the influence of culture, in that our culture is pretty screwed up about body ideal, especially for women. And it is hard to be a young woman or an older woman in our society and have a positive relationship with your body because of the cultural messages about how women should look, which is basically unattainable unless it is a full-time job or you have a lot of plastic surgery.

There was a fascinating study by Anne Becker and her colleague. She went to Fiji and happened to be there right as they were getting Western television. Fiji is a Polynesian culture in which typically the ideal body type was the voluptuous large woman, and they were seeing Western TV with our ideal body types—very thin. So she had a chance to study girls and young women, and what was fascinating but sad is that over the time that television was there, the girls basically stopped liking their voluptuous bodies. They started dieting, talking about dieting; there was a lot of peer stuff about food and weight and appearance, consciousness which hadn't been there before.

It is not a true experimental design, but it is pretty compelling. These young women were from a culture that had historically had an ideal of a heavyset look for women—yet some of them started spontaneously throwing up because they felt they had eaten too much, which could be a symptom of bulimia. Very sad. So culture is clearly part of the equation for both anorexia and bulimia.

RR: That's exactly right. Because this is a multi-determined category of disorders, there is no one factor that stands out, but people with eating disorders often report having been teased about their appearance or body size or shape. At least, these experiences are on their minds in such a way that they tend to report them. So that is another cultural piece, if you will.

Personality factors or being perfectionistic—that is particularly true for people who have a restrictive type of anorexia. The thought is they will diet and then they keep dieting. It is a very slippery slope of weight loss.

People who binge and purge or have a binge/purge-type anorexia may have some issue around impulsivity or emotional regulation. Sometimes they will have more substance abuse issues, alcohol in particular. There is sometimes a cycle where they become disinhibited by drinking, and then they overeat, and then they feel bad, and then they throw up or purge and whatever they do with the eating. Frequently, they exercise the next day.

RR: Exactly. In fact, people who binge talk about using it to zone out, to get away from themselves, but then they just feel really bad afterwards, so it doesn't really work. It works in the moment, but not later.

RR: The biggest one is a family preoccupation with weight, food and appearance, or being teased in other ways, their body shape being an issue—which makes sense, right? If your family is really attuned to how you look or how they look, that is what you learn and what you internalize. There appear to be some causal biology issues as well, but that is also very hard; it is sort of a chicken-and-egg thing, because people often don't come to the attention of research studies until they have an eating disorder. And once your eating is disordered, you are changing your biology.

So there are lots of associations, but it is just not clear. Sometimes eating disorders run in families. Is that genetic coding? If a parent had eating issues, the odds are that there will be a family dynamic around food. So is that genetic or is that biological? They are trying to tease this part out. Is the eating disorder co-morbid with a mood issue, which could explain why antidepressants might work for people with bulimia? I think the biology part maybe a bit oversold. People have different temperaments that make them vulnerable to different sets of disorders if environmental circumstances trigger them. But I don't think it is the case where someone has the gene and therefore he or she gets it.

RR: Right. It's not as if eating disorders typically arise across like multiple generations in the same family.

RR: There have been people with anorexia in recorded history going back quite a while, but they were mostly young women or older girls, and it was religiously motivated—a sort of asceticism. There weren't issues about body image per se. And in current times in Asia, at least 10 years ago when they did some of these cross-cultural studies, some of the young women with anorexia didn't say that they felt fat, but they complained that the reason they didn't eat much was because they didn't like the way that they felt. They did not express the same fear of weight issues that Western girls or adults with anorexia have.

The other thing is that 30 years ago anorexia was a kind of white upper-middle-class disorder; now it is an equal opportunity disorder.

RR: It is hard to figure out what is normal eating for a woman in our society. It is hard to sort out where the line is between normal and abnormal size. When guys are hungry, they eat; it's fuel. But it is really hard for women to view food as fuel that they need and not use it in other ways, and listen to their body about when they are hungry and full and not be externally regulated—"This is the amount I should eat, and this much is too much," or that kind of thing.

So many women feel fat, or feel fatter than they actually are. Is that body dysmorphia, or is that just part of what women think it means to be a woman? Is that what our culture tells us women are supposed to do? Women say, "How do I look? Do I look fat in this?" That is part of the culture.

Real dysmorphia is preoccupying—it is almost delusional. They have done some studies on women with anorexia: they have an Adobe Photoshop morphing program where there is a photo of them and they can turn a dial to make themselves thinner or heavier. So you ask them to adjust the image to what they think is their actual body size. Some of the studies show they are actually pretty accurate—it is not that they necessarily see themselves as heavier than they are—but some studies don't show that. It is a little hard to say.

The dysmorphia isn't about being unhappy with your body; it is really thinking that your body is different than it is. And I think it is not uncommon for people who were heavy when they were younger—no matter how thin they are, they may feel like they are heavy. It is not a dysmorphia—it is just how they encoded their body image, and it is really, really hard to update it accurately. It is like people who grew up poor: no matter how much money they have, they often feel poor. It's not like they are delusional. They know that they have this money, but it's hard to fully accept the new circumstances in a deep way.

RR: I think people come to it for really different reasons. It's sort of like substance abuse. There are many different reasons why people start this slippery slope of using or abusing a substance. But once they are dependent on the substance, it takes on a life of its own, and ultimately they all look similar at that end of the process. Some people start out trying to lose some weight. It feels really good. They get a lot of positive feedback about it. They say, "Okay, I will just lose a little bit more, a little bit more." And then, before you know it, they are underweight and their self-esteem has gotten tied up with it. They have gotten this reinforcement from, who knows, their boyfriend.

And then it is really hard to come out of it, because depending on how underweight you are, you start having some cognitive impairment issues, and then it is hard to make good decisions. Bulimia or binging and purging is a similar thing: it may start out where someone ate so much that she felt either physically uncomfortable or emotionally uncomfortable with how much she had "pigged out," so to speak. So she may have made herself throw up, and then in that moment she felt better—there was immediate positive reinforcement for the behavior. So the next time she feels uncomfortable she thinks, "Oh, well, this worked last time. I will do it this time." And then she does it again and she start to think, "Well, it's okay if I overeat, because if I do, I can just throw up, or I can take laxatives, or I will just do another half hour on the Stairmaster," or something.

Then it becomes a slippery slope. It is not necessarily for attention, but once they do it, it becomes a coping strategy that it is hard to switch off. And it often becomes the primary coping strategy.

RR: Yeah, it's really sad. It is one of the downsides of the Internet. It is ubiquitous—if you want that kind of support, it's there for you. And I think it is really hard for families and caregivers, because you can't forbid someone to use the Internet, so it is much harder to control the environment in a way that is positive.

RR: I think that is one of the differences. I think there is also a "me, too" copycat issue. In psychotherapy, there is a certain competitiveness that happens. It is not just advice. If you have a therapy group of women with anorexia, you have to have a skilled group therapist to make sure that the group doesn't end up being de facto pro-ana. You don't want people to get into this competitive "I'm thinner than she is, I eat less" dynamic.

RR: Sometimes the individuals recognize they have a problem—either they saw something on television or a film or online. Or they vomited up some blood or they passed out. Sometimes people just feel like it is taking over their lives and they haven't quite realized it until they were late for some event because they were engaging in these behaviors. Or a friend was using the toilet, the bathroom was left disgusting, and they had a fight.

Sometimes it is family members being concerned. Sometimes if they are under 18 or even if they are college age, parents may say, "You have to do this," or, "We won't pay for college if you don't do this." So there may be a certain level of coercion.

RR: I think it depends on why they are there. If they are not there because they want to be, then they may be tempted to minimize it. I think it is like substance abuse in that way. If people are really there because they feel totally committed and want to be there, they are likely to be more honest than people who are ambivalently there.

RR: Great question. One of the things that is really important for psychotherapists treating eating disorder patients is to work with either an internist or a pediatrician who has experience and knowledge about medically treating eating disorders. This is super important, because as the psychotherapist you don't want to get into that dilemma of having to be the bad cop, or any cop. You just don't want to have to be monitoring their medical status. And frankly, most mental health clinicians don't have the training. Even psychiatrists shouldn't be in that role because that is really a medical role.

And not all internists and pediatricians really know how to monitor patients with eating disorders. They don't necessarily know what to look for, and they don't know how patients might try to game the medical exam. For example, a good practice for any kind of eating disorder, and patients who have anorexia in particular, is that they should be weighed every time they come in. And they should be weighed with only a gown, because sometimes anorexic patients will put weights into their clothes to make themselves heavier on a scale so it looks like they have gained weight. If you have them wear a gown, or even if you don't, you really need to palpitate their bladder, because sometimes patients will water-load before they come in as a way of being heavier on the scale. Water-loading is very dangerous because it can make their electrolytes go all out of whack. So there are all these things that you wouldn't necessarily think to do.

For eating disordered patients, the internist should explain that they have to be weighed every time. If they don't want to know the numbers on the scale, the internist is happy to weigh them backwards, or have the nurse or the physician's assistant weigh the patient backwards. Sometimes patients freak out by the numbers on the scale every time they come in, if it is up or down or that kind of thing. It can be devastating for patients to see the numbers on the scale show they are gaining weight, even if they know that they are and they should.

RR: It's really good to have a dietician who knows about treating people with eating disorders. Sometimes a dietician who doesn't have specific training in eating disorders can do more harm than good. It is really about specializing. They are a valuable part of the program because they can look at a patient's food chart and see, "Gee, maybe you are having cravings for ice cream because you are not getting enough fat earlier in the day. So what happens is by dinner time you are not being sustained by the food that you are eating because you need fats to give a sense of satiety."

So if they are basically having a low-fat diet, they will be much more likely to be at risk to binge later in the day. It is little things like that, where even a nutritional consult can be helpful.

RR: I leave the medical decision to have someone do residential treatment to the person's pediatrician, doctor, or internist. We consult with part of a team, but at some point it is a medical decision, which means it is really not safe for the person to be doing what they are doing on an outpatient basis.

There are various steps of care for eating disorders. You can have a 24-hour inpatient experience. You can have residential, which means that is where they sleep. They have a dinner meal and they sleep there, but during the day they are doing other things. You can have a day treatment, which is their 9 to 5, but then they sleep somewhere else. You can have intensive outpatient treatment, where the person comes three to five times a week for a psychotherapy session, or more regular once- or twice-a-week outpatient psychotherapy.

There is a range of different options available depending on the severity, the patient's motivation, insurance issues, or practical issues. Sometimes residential is really the best course of action because the eating is so out of control that they need an environment that is totally structured for them 24 hours a day.

The main problem with residential is that when people leave, they typically go back to the same environment that they came from, and they have all the situational cues. It's like putting an alcoholic in detox—if afterwards you put them back with their friends who are going to bars, or they have all of the alcohol in the house, or they haven't learned new coping strategies adequately, then they are kind of back to square one.

RR: Right, depending on the situation. And honestly, unlike alcohol, someone can not drink, but you can't not eat. And I think that is one of the hardest things about recovering from an eating disorder—it is really having to figure out how to do it in a different way. It is not an all-or-none thing. And it is really hard, I think, to figure out how much food is enough. When should I get up from the table? How hungry should I be before I start a meal? How hungry should I be to have a snack?

RR: The kind for which the patient is most motivated. The track record in research studies is for cognitive behavioral therapy; that is the gold standard and the treatment of choice for bulimia. For young people with anorexia, if a family is willing to do it, there is what is called the Maudsley Approach, named after Maudsley Hospital in England, which is where the treatment originated. The idea for this treatment is that the therapist's role is to support the parents and the parents' wisdom and authority in getting their child to eat. So the child lives at home, and one of the parents is home 24 hours a day, and they alternate. The idea is that the kid can't do anything until she eats, and as parents it is their right to get their kid to eat. But you don't want to literally force it down her throat, so the therapist is a consultant helping the parents use their knowledge of their child and their authority to help the person eat. There is a great book for the Maudsley Treatment called Treatment Manual for Anorexia Nervosa. 

RR: It is incredible intensive. It is a huge family investment in time and energy, and it has a very good track record. But obviously, you are not going to use this with a 30-year-old.

For people with anorexia who are older or for whom Maudsley doesn't make sense, if they are medically stable, so they don't need to be in an inpatient unit, cognitive behavioral therapy can be very helpful. But the main problem with cognitive behavioral therapy for people with anorexia is if they are underweight enough, their cognitive functioning is compromised; it is subtle, so patients don't always realize that their cognitive functioning is compromised.

So what happens is that you can't really do the cognitive work, because they can't do it. They can pretend to do it, but they believe that their thoughts about food are actually rational.

RR: If this is because they are underweight, you may actually want to do a brief inpatient or day treatment stay to get their weight into a healthier range so that the cognitive functioning is better.

Sometimes depending on how old they are, their living circumstances, they are having family therapy or even couples therapy, if they are older. And they are trying all different kinds of things. Interpersonal therapy (IPT) is being used for bulimia. It has actually got a pretty good track record. Most people don't have training in IPT, so it is not as widespread. Another thing that can be helpful is dialectic behavioral therapy for people with intense bulimia, because it is really an emotional regulation problem, so DBT aimed at helping with emotional regulation can be very helpful. Researchers are beginning to apply DBT as a way of treating bulimia, and results are encouraging.

RR: What might make sense before clients are referred out is if therapists are willing to have a consult with someone who has this expertise in eating disorders, because it can't hurt. If the psychotherapist doesn't have an expertise in eating disorders, even in a one-shot consultation they will learn something that will help them for other patients in their practice. They themselves will get to ask that question—"What is the cutoff? What are the questions I should be asking patients when they mention eating that seems a little odd to me?"

Therapists who are at all wondering if a consult is a good way to go should do what therapists naturally do when a flag goes up with something a patient mentions, which is to ask more about it. Try to get a little bit of a history of the problem. Does the patient see it as a problem? Do family members or friends mention it? What does the patient think the function is? What function does it serve? What are the drawbacks? What are ways in which it seems the patient thinks it is working for him or her to have that disordered system? So collect information.

When there is any doubt, a consultation is a really good idea. Or, if it is really clear that the person has a problem that is enough out of the therapist's expertise, he makes a referral and explain to the patient, "You know, it's not necessarily an 'eating disorder,' but it sounds like it is enough of a problem in your life that it is worth just getting some advice from someone who has an expertise about this."

Again I wouldn't frame it as the person should enter lifelong eating disorder treatment. If the therapist doesn't think she needs a consult herself, let the patient have a consult.

RR: One of the things about the process of becoming a better therapist is figuring out the kinds of clients that aren't a good fit for you. And patients with eating disorders are definitely not a good fit for some therapists. One of the things is just to realize that and there is no shame in that. It's really not an issue. We all have kinds of patients who we work better with and kinds of patients that we work less well with.

So if you as a therapist feel like, "Ugh, I don't really want to get into this. This is just not my thing," that's really useful information and it may make sense to refer the person to someone else.


Again, I think the best thing to do when that happens is to have a consultation. I am a big believer in either peer consultation, groups with people who have an expertise in eating disorder or paying for a consult, but if you feel like you are not being as helpful as you can, if it feels like the treatment is standing still, it is always good to get another take on the case. That is where we have case conferences and things like that.

The easy cases, where the work gets done very quickly, usually happen when it is a newly diagnosed eating disorder or new onset, and the person is really motivated. But I think more and more there are the chronic cases where people have been doing it for a long time and it is one of the main coping strategies that they have. And if they got the eating disorder at a young age, they never really developed themselves as people outside of the eating disorder, so they don't actually know who they are. There is no baseline they can return to. And it can be very slow-going work. The patient may be ambivalent about getting better, so it may feel like it is two steps forward, one step back, or just sometimes like you are standing still.

RR: I think it is my own impatience to want to help them get better sooner.

RR: Yeah, exactly.

RR: Yes. One of them is people who aren't squeamish about talking about vomit, about loose stool, about bodily functions in great detail. If someone is uncomfortable about that, then it is definitely not a good fit. Some people may feel like they are being too intrusive to ask the kinds of questions that should be asked: "How often are you throwing up? How do you throw up? What does it feel like when you throw up?"

The other part is there is a lot of work about body image. The actual eating disorder symptoms sometimes, with appropriate treatment, can get better remarkably quickly. But what happens is residual body image issues remain; the person may be eating in a normal way but he or she doesn't like their body, they may be cutting—not parasuicidal cutting, but they make little marks with a razor on their thighs, that kind of body hatred. That is a different level of work that then has to get done.

RR: If people are having that kind of self-harming behavior, probably DBT, dialectical behavior therapy, or some of those techniques can be very useful because, again, it is about emotional regulation. If you hate your body so much that you hurt yourself like that, then I would say DBT is a good way to go.

Often, there are psychodynamic issues as well. And there is a fantastic workbook by a man named Tom Cash called The Body Image Workbook, and it is just a fantastic book—well researched, very effective treatment for body image issues. The main problem is that people don't necessarily want to do the work that is in the workbook. They have to be really motivated to do it. It is a lot of record keeping and exercise, not physical exercise but things like "stand naked, look in the mirror"—Mirror Exposure, it's called. And that can be really hard for people. So therapy can actually be helpful in getting people over the hump to do that work.

RR: Absolutely. I have a deep respect for people's ambivalence about getting better, and about how the longer symptoms persist, the harder it is to turn them around because people forget who they were before. The saddest part about eating disorders developed early is there was no "before."

But that's generalizing. The other thing is just the awesome human spirit and the general capacity to try valiantly to cope. Human beings are amazing, and to a certain extent we are very resilient. Eating disorders, in some sense, are a type of resilience that just went awry, that became pathological.

RR: If you are having a hard time, if your boyfriend broke up with you and you are sad, it's not uncommon in our culture to go have some ice cream to console yourself. People are just trying to do the best they can, and I think that is true for eating disorders. People who are depressed who struggle valiantly to get out of bed in the morning when they just want to curl up—the fact that they get out of bed is amazing. That is what I mean about the human spirit to keep going, despite all of the things that people are juggling and the mental and physical handicaps, being exhausted, feeling like they are going to faint, just not being able to function well, being preoccupied with lots of food.

Most people, most of the time, are able to put one foot in front of the other and keep going in trying to get better.

RR: I think it is about the essential human contact of really hearing someone in the fullness of who they are—the good, the bad, the ugly—and their profound relief at being accepted for who they are. And then the sense of being able to help them. The amazing thing is, when therapy works, the idea that you helped make someone's life better.