July 21, 2009, 12:41 pm
Is Anorexia a Lifelong Illness?
Jeremy M. Lange for The New York Times Margie Hodgin, featured in the Times story “ When Eating Disorders Strike in Midlife,” is among many people who struggle with anorexia and related problems well beyond the teenage years.
Dr. Kathryn Zerbe, professor of psychiatry at Oregon Health and Science University and a longtime expert on eating disorders, recently took readers’ questions on anorexia, bulimia, binge eating and related problems. Here, she responds to various questions on treatment of eating disorders, how to pay for therapy, and whether conditions like anorexia and bulimia can be cured.
Can Anorexia Be ‘Healed’?
Dear Dr. Zerbe,
Do you believe that people can actually be “healed” in the sense that they no longer struggle with eating? I am a 38-year-old “former” anorexic. Standing 5 11 , I’ve gone from 110 lbs to 155 in the last few years, after finally admitting to myself and my therapist that I had an eating disorder. However, I still notice many of the same thoughts sneaking in, particularly when I feel the physical sensations of hunger or fullness, though I now manage the thoughts.
In your experience, is there typically a bit of a struggle that never really goes away? In other words, I am wondering if I should continue to push myself or if this is it.
Dr. Zerbe responds:
I do believe that people can be healed, even after a lifetime of struggle with an eating disorder, so it is worth “pushing yourself.”
We do need to define what “pushing you” means. Getting better should be about a lot more than just dealing with the eating symptoms and weight fluctuations. It means dealing with feelings, wishes, fears and any hidden meanings that underlie the problems. I tell my patients that we all have a psychological relationship to food. That is one of the other areas that need to be explored in therapy.
There is also the delicate balance we all must achieve in becoming ourselves autonomous human beings while staying connected to others. We refer to this as “healthy dependency,” and it simply means the many ways we must develop to reach out to others and let them reach out to us.
When you have more going on in your life in terms of relationships, a career or hobbies you like, and especially if you can develop an interest you are passionate about, you will become less preoccupied with those physical sensations of hunger or fullness. I congratulate you on managing the thoughts better now because that takes practice and the will to change. It sounds like it is the perfect time to take the next step to have a fuller life.
A Daily Struggle With Anorexia
I have had anorexia for 7 yrs. now, and can’t tell you how hellish each day seems. I try and try to get better, but my fear of gaining weight hasn’t helped. My parents are completely out of money, I am getting old, just turned 25, and really want to get married, or at least have a boyfriend. I see a doctor and a nutritionist weekly, but just don’t trust anyone that you can be skinny and eat a lot. I currently eat 6 times a day, and am doing better weight wise than I have been, but still don’t have a period (can’t remember the last time I had one, maybe 4-5 yrs. ago). They say I still need to gain at least 10 lbs., which is beyond my comprehension, I don’t know what to tell myself. The media is so hard, especially living in NY and seeing so many twigs. Please help, what do I do?
Dr. Zerbe responds:
Where is it written that every person should look the same, or as you put it, be a “NY twig?”
There are so many natural body shapes and sizes. Heredity plays a role in this, but so does environment. If we eat too much, most of us can put on weight. If we eat too little and deviate too much from our body’s normal “set point,” we don’t just lose pounds but expose ourselves to many health risks, including heart failure, anemia, body chemistry imbalances, osteoporosis and dying from malnutrition. That should set off the alarm to really try hard to ignore what appears to be the fashion and entertainment industry ideal and very slowly increase your calories to gain a little bit of weight every week, best done under medical supervision.
It may seem like an impossible aim to you now, but making the decision to control the behavior instead of allowing the starving and the behavior of others control you can be done. Aim to establish an identity that is your own and not built around body image or being skinny. Put into place a plan for personal growth, practicing balance and moderation in all things.
Also, as I have noted in some of my responses to others, there is low cost treatment available, especially in big cities like New York. If you are serious about getting better and have already tried many of the established cognitive-behavioral tools, you might consider a more intensive psychotherapy process under the auspices of one of the psychoanalytic institutes in New York.
Psychodynamic treatment not only provides a lot of support because you meet frequently with your therapist (at least once, and sometimes up to four times, per week), but it also can help you explore emotions that underlie your symptoms. Sometimes people use or misuse food to ward off painful feelings, or they need to work on losses that they might not consciously be aware of having. A therapist who you experience as “on your side” will help push you to understand why you are having such trouble gaining weight when it is clearly in your best interest to do so. That’s what I mean when I say that patients often have to get below the surface of their manifest symptoms to make really lasting change, especially if they have had their problem for a while.
I am beginning to see research on Body Identity Integrity Disorder (BIID) and anorexia. As a “recovering” anorexic, I can definitely identify with the inaccurate perception I have of my own body. It’s not that I “just don’t like it” or I “feel fat.” Rather, when I see a woman my same relative height and weight, she looks completely different to me than I look to myself. I describe it to my therapist as if “my eyeballs are broken.” What I see is not at all what someone else sees.
I felt a sense of relief as I started to read some of the studies, as if the research is beginning to explain w
hat I’ve experienced most of my life. Any thoughts on BIID?
Dr. Zerbe responds:
It is very likely that a brain-based mechanism is involved here. The field of eating disorders is fortunate to have many experts who spend a great part of their working weeks looking into why people who recover may continue to “see” others as different from themselves.
A number of medical and physiological problems persist even after target weight or B.M.I. (body mass index) is restored. Just one of the neuropsychiatric consequences that may take a long time to resolve is an accurate perception of your own body image and how you “see” it compared to others.
In follow-up of the classic work of Dr. Ancel Keys, a specialist in endocrinology who studied the effects of human starvation on healthy volunteers during World War II, several of the volunteers admitted to having continuing symptoms of food preoccupation, binge eating and problems with body image long after they were finished with the study and had achieved their target weight.
Digging Deeper Into the Causes of Eating Disorders
Dear Dr. Zerbe,
I am in my late 40s, have BED, Bulimia and anorectic tendencies. I haven’t heard of this much, but in my case the binge-eating was triggered by an anti-depressant (long ago), which started my disordered eating. This is the opinion of my current doctor, who has referred to my eating disorder as “iatrogenic.”
I literally can not keep any food in my house, including fruit, plain yogurt, etc, because I will binge on ANYTHING. Though my first choice would be sweets. I alternate between periods of binge-eating of MASSIVE quantities of sweets … for weeks or months or longer, and at some point I seem to be able to stop the binge cycle but can wind up on the overly restrictive end of the spectrum
I am a member of overeaters anonymous, which has provided me with incredible support, but has at the same time filled me with fear as in ” One never knows which cookie will be the 150 lb cookie-” ; The all-or-none sugar as alcohol approach.
I have been in and out of treatment programs, inpatient, outpatient, etc. Often, the treatment has been aborted when the insurance company has seen fit to “pull the plug” despite the best attempts of the treatment teams. The Psychiatrists and Psychologists who specialize in the treatment of eating disorders rarely accept insurance of any form.
If you have any suggestions, please let me know. Do you advocate any particular type of therapy for eating disorders, i.e Cognitive Behavioral, etc.?
BTW- if there are any Doctors reading this, please take complaints of binge-eating seriously. I tried so hard to communicate to my internist that the urge to overeat was overwhelming and that I had no control over it and he did not acknowledge or understand this. I believe that this was a major component in my having become bulimic. Bulimia now that is a “Real” Illness, while Binge Eating well, that is apparently to some, or many, just the example of another lazy, fat American.
I am not saying this with malice. If one doctor reads this and decides to take a complaint of out of control eating seriously in the future and helps that person before he/she becomes bulimic I would be very grateful.
and for anyone who may be reading this who thinks bulimia could be any kind of possible solution- PLEASE, PLEASE DO NOT ATTEMPT TO INDUCE Vomiting.
Try to imagine how awful you will feel when your teeth become transparent and discolored and you know you will need $30,000 + of dental work I didn’t listen to my bulimic friends in OA and now ironically, in an effort to avoid obesity and to be attractive, I have ruined my appearance further. It is easier to lose weight than to grow new teeth! not to mention the possibilites of esophageal cancer, burst esophagus, electrolyte imbalance, death, etc.
Dr. Zerbe responds:
I agree with my colleague G. Terence Wilson (see the Times story, “What to Ask Your Therapist About Eating Disorders”), who recommends finding a therapist who is flexible in approach and knows cognitive-behavioral techniques that can be so helpful in the treatment of full-blown anorexia, bulimia, binge eating disorder and the “subclinical” eating disorders.
You are right to remind health professionals and those who suffer from these problems about all of the physical and emotional tolls that they take and to be on the lookout for all of them. Because recovery tends to be slow for many, and relapse rates are high even after treatment, it may be important to look at therapy a bit like “weeding a garden.” Behavioral suggestions are like pulling out the weeds; they are an essential step, but after you are feeling better you may need to “dig deeper” to get to the root of the problem. Then the weeds have less of a chance of growing back because the roots have been pulled out.
More and more therapists who treat eating disorders are now blending cognitive-behavioral therapy and psychodynamic therapy to insure better outcomes. (See Heather Thompson-Brenner and Drew Westen’s important 2005 study on this in The Journal of Nervous and Mental Disease, “A Naturalistic Study of Psychotherapy for Bulimia Nervosa, Part 1: Comorbidity and Therapeutic Outcome,” and “Part 2: Therapeutic Interventions in the Community.“) I am fond of quoting to my own patients a statement by psychologist Lucy Daniels, who wrote about her recovery after suffering from a longstanding eating disorder like your own. She found that understanding herself in psychodynamic therapy was essential because, as she writes:
- “It provides support during the process of working through conscious and deeply unconscious separations and for bearing the pain that such losses entail. It maintains a sense of being listened to intently by a thoughtful person who will not let you be self-destructive without at least asking a question, but who will also, unblamingly, let you accept the consequences for your mistakes….” She continues: “thoughts and feelings expressed freely allow reality to emerge.”
Good luck to you as you take the next steps on your own journey. It is clear to me that you are confronting yourself with some of the long-term effects of having an eating disorder and trying to help others by warning them about some of the less well known but life threatening consequences.
Insurance Coverage for Eating Disorders
I am not surprised eating disorders are surfacing in middle age. When people in their 40s, 50s, and 60s struggled with eating disorders the medical community and public were less aware of these problems. People with binge eating disorders as well as those around them thought binge eaters just needed to diet. Doctors rarely questioned you about being under weight and if you were overweight sent you to Weight Watchers or gave you diet pills. Thus we are seeing more eating diorders in middle age because we now have a diagnosis for it and the medical community is trained to spot it.
I have suffered from binge eating all of my life. There are times when I want candy, specifically chocolate, so badly by body starts to shake as if its going thru withdrawal if I don’t get a fix. I’ve described the experience of wanting chocolate so badly that its like anitch in the middle of my back that I can’t reach to scratch and so you squirm and writhe until you get r
Cognitive behavioral therapy is great but I find it very difficult to implement the techniques learned in therapy when I’m in the midst of a high intensity craving.
I would like the doctor to address what the medical community is doing to get health insurers cover treatment at residential facilities for binge eating. Currently most insurance plans in NY don’t provide coverage. Yet such treatment might be a better alternative to gastric bypass surgery for the morbidly obese.
Dr. Zerbe responds:
A number of eating disorder experts have testified to Congress about recognizing eating disorders as real illness and making sure that treatment for them is funded. Some families are also taking up the banner with their insurance carriers to make sure that their loved one gets treatment, but as you are aware, this is often a lonely, individual fight.
In medical, nursing, dental, psychology and social work schools, we are teaching more about eating disorders and trying to raise awareness. Here is one interesting but sad story. A colleague of mine sent her Powerpoint slides to a fourth year medical student class she was teaching on anorexia, bulimia and “EDNOS” (eating disorders not otherwise specified, which includes binge eating) so that the students would have all the information beforehand and be able to ask questions. Several of the students sent her back questions and concerns about how to get help for a friend of theirs that they knew had an eating disorder. This shows you how important your question is regarding the need to have more access to care and to get the core information out to health care providers.
You can learn more about what is happening at the national level to get coverage by going to the following organizations’ Web sites: the National Eating Disorders Association; the Academy for Eating Disorders; and the National Association of Anorexia Nervosa and Associated Disorders.