Blame it on the sertraline?

This story from the U.K. links sertraline--the generic name for the antidepressant Zoloft--to a young woman's death from anorexia.

"One of the side effects is the reduction of appetite," said the psychologist who treated the young woman.

What will it take to make people understand that anorexia is not the result of reduced appetite? That it's a brain disorder with genetic and biological underpinnings?

Many people (including myself) take sertraline without becoming anorexic.

Just once, I'd like to see a news story that showed a true understanding of anorexia. Just once.

Need a laugh?

Things have been a bit slow on the blog lately. Sorry about that--being a first-time professor takes up a lot of time, as it turns out! This post, The OCD Diet, should make up for that. Don't read this at work, unless you don't mind falling on the floor laughing hysterically in front of your colleagues.

We STILL don't get it

I was saddened to read today of a woman in York, England, who died of complications from anorexia. Carole Patrick had struggled with anorexia for 30 years, according to this article. Chronic malnutrition led to osteoporosis, which led to a fall that broke her hip and made it impossible for her to recover when complications developed.

But I was shocked to read this line, buried in the article:

York Coroner Donald Coverdale, recording a verdict of death by misadventure, said her death was the “unfortunate and unintended consequence of a medical condition arguably under her control."

You would think medical people, at least, would understand that anorexia is not a choice. Anyone who's ever watched someone they love suffer with an eating disorder understands this basic fact; why can't the medical profession get it?

A few paragraphs down, a spokeswoman for BEAT, a UK-based organization supporting people with eating disorders, had this to say about anorexia:

. . . disorders such as anorexia were not a “diet gone wrong” or a fad or a fashion. “They are a way of coping with difficult thoughts, emotions or experiences,” she said.

In some ways, this shocked me even more. This is the old psychodynamic perspective on eating disorders, one that has been in vogue for 50+ years. Only thing is, there's absolutely no evidence that it's true.

The latest research points to genetics and heritability as primary factors in eating disorders. EDs run in families. They're associated with clinical levels of anxiety. Many people have difficult thoughts, emotions, and experiences; very few of them develop eating disorders.

I don't expect most people to understand anorexia; we have a lot of educating to do. But I do expect medical people and organizations like BEAT to know better--or to stop speaking for all those with eating disorders.

Of parents, health, and eating

This semester I teach mainly seniors, and today I was asked by some folks in another part of the university to administer a health survey to my classes, to gauge the effectiveness of some "healthy living" efforts they've been working on for the last few years. I couldn't help noticing, as I collected the surveys, one line in particular. It was one of a series of questions about where these 22-year-olds get their health information. There were many choices (the internet, magazines, newspapers, classes, health initiatives on campus, etc.), and many of the students indicated that they didn't get health info from very many sources. The one source that almost unfailingly scored high: their parents.

That's right. Their parents. These young women (and a few men) have been living away from home for the last four years. They've been independent. They've traveled to Europe, many of them; they're close to starting their own adult lives. And yet they trust their parents more than almost any other source of health information.

I must admit that tears came to my eyes as I looked at survey after survey (just that one line, honest!).

This was especially moving and poignant given what I'd been reading earlier in the day: A book called Psychosomatic Families by Salvatore Minuchin, one of the founders of family systems therapy. Minuchin's work with families is often cited as one of the inspirations for family-based treatment of anorexia and bulimia. Until Minuchin's work, patients were routinely separated from their parents and treated (usually ineffectively) individually. Minuchin was one of the first to see patients as part of a bigger family system.

Unfortunately, his view of families was anything but positive. The title says it all: Instead of psychosomatic patients, he believed in psychosomatic families--families that through enmeshment, conflict avoidance, triangulation, and other unlovely psychodynamics created children who expressed their emotions through illness. Interestingly, Minuchin writes that he developed the idea of psychosomatic families after treating diabetic children who managed their blood sugar fine in the hospital but who had crisis after crisis when they were at home. His theory was that emotional stress at home was affecting the kids' blood sugar levels.

It's an interesting theory, and I think there's some merit in it, but not for the reasons Minuchin believed. As this rather technical article discusses, stress early in life can lead to permanent changes in physiology--in this case, rats' guts became more permeable, leading to more gastrointestinal symptoms. The idea is that some of us (rats or humans) may be more genetically predisposed to such stress mediation than others. Genes load the gun, environment pull the trigger.

For Minuchin, though, it was all environment. He blames parents for pretty much everything. For those of us who have parented children with eating disorders, his book is painful reading. For instance, Minuchin describes a family at the table with their anorexic daughter. Each parent tries to cajole, threaten, and inspire the child to eat. The child does not eat. Minuchin deconstructs the parents' behaviors as "enmeshment."

He was way off base on that one. By the time a child is in that kind of trouble with anorexia, of course parents are going to be trying to get her to eat. And of course they're going to be unsuccessful, unless they're empowered or supported by the treatment and/or professionals. Sitting in a room with a one-way mirror, pleading with their child to eat, most parents will look enmeshed and ineffectual.

Which is why I was so moved to see those answers on the surveys today. One of the fundamental principles of the Maudsley approach is that families love their children and are best positioned to support and help them through one of the most devastating experiences of their lives. Critics of Maudsley say the treatment fosters an inappropriate "enmeshment" (that word again) between parents and children. Proponents say Maudsley leverages the asset that already exists: the strong and loving relationship between parent and child.

Not all families are healthy. Not all families are functional. Not all parents love their children. But most do. And if those surveys are correct, for many adolescents and young people, parents are still an important part of the picture. And not in the way Minuchin imagined.

Update: Rogers Hospital

I got an email from the family whose daughter was being held hostage at Rogers: Their daughter came home last night. Against medical advice, but she's home.

Sounds like Rogers was still trying to bring the county in, right up to the last minute, but the family had done their homework and was able to challenge Rogers' assertions.

Now, of course, comes the truly hard part: re-feeding a 13-year-old with anorexia. But this is a wonderful example of how families that are empowered can accomplish near miracles--especially when they're motivated by love of their children.

To the family: You are awesome. As hard as re-feeding is, I found it infinitely preferable to be doing it myself, at home, rather than be far away, feeling helpless about whether my daughter lived or died. We're all rooting for you.

America the Beautiful

Anyone out there see this movie yet? I'd love to hear a report from someone who's actually had a chance to watch it. It hasn't come to Syracuse yet as far as I know. The trailer, which you can watch online, looks great.

Beacon Street Girls: books to help teens lose weight

I'd love to see readers of this blog weigh in on this post by the usually savvy Tara Parker Pope in her Well blog at the New York Times. From the comments on the blog so far, most readers just ain't getting it. You can help. :-)

Why I don't recommend Rogers Memorial Hospital: Part II

Last year I wrote about the cognitive dissonance between the marketing materials produced by Rogers Memorial Hospital, in Oconomowoc, Wisconsin, and its actual therapeutic programs and practices.

That post produced a letter from Rogers' CEO himself, complaining about my "airing my grievances in a public forum" rather than talking directly to him about them.

Dude, that's what blogging's all about. Besides, I can imagine how open he would have been to my criticisms. Yeah, right.

This time around, I'm not just writing about presentation. I'm writing about practice, therapeutic practice as it's being executed at Rogers. And it stinks.

It seems that Rogers has changed its practices around the use of feeding tubes for anorexic patients. In the past, feeding tubes were considered something of a measure of last resort, sometimes necessary to save a life but something to be avoided when possible.

Not anymore. And not only that: feeding tubes are being used to keep patients at Rogers when parents want to bring them home.

Case in point: A family whom I'll call the Smiths, whose young adolescent daughter was admitted to Rogers a few weeks ago. The family was told the girl must have a tube, and although they weren't in favor, the tube was administered. Fast forward 10 days or so. Rogers is telling the family the girl has made "little progress" and urgently needs admitting to its 30-day residential program. Family can get no information on why so little progress has been made, even with the tube. Family has been researching, and has decided they want to use family-based treatment, the Maudsley approach, to help their daughter. Family tells Rogers of their intentions and asks when daughter may be safely transported home.

Next thing family knows, their local county department of child protection services is threatening to remove their daughter from their custody if they take her home. Rogers continues to insist that daughter cannot be moved so long as she's on the tube. Family says most girls with their daughter are also on feeding tubes, which constitutes a large shift in treatment protocols at Rogers.

The girl is eating. She's terrified. She wants to go home. Her family wants to bring her home for FBT. Rogers, which claims that it incorporates some FBT in its therapeutic protocols, is playing dumb and insisting that FBT would constitute child abuse and that the girl cannot safely be sent home.

The therapists at Rogers are (or should be) familiar with the studies on FBT, which show that it is very successful for adolescents under 18 who have been sick for less than three years. (It's been successful for others, too, but there are no studies yet on those populations.)

Their actions in this case and others are deeply disingenuous. Feeding tubes are a necessary evil at times. But families should be the first line of treatment and support for adolescents--especially when the family is committed to the task of helping their child recover.

Shame on Rogers.

Why I don't fast on Yom Kippur

Millions of Jews around the world are fasting today, in observance of Yom Kippur. From sundown last night to sundown this evening, they will drink and eat nothing, in honor of the most sacred day of the Jewish calendar: the day your fate is sealed in the book of life for the coming year.

I am not fasting this year, or next year, or any other year. Not because I'm too gluttonous to give up food and drink for 24 hours. Not because I think it's irrelevant.

I'm not fasting because of what it means to be to be hungry, to be fed, and to be strong.

Let me tell you a story: My first Yom Kippur fast happened the year I turned 13--an adult for the purposes of Jewish law. I wanted to fast. I wanted to behave like an adult. I wanted to look pale and weak, to feel my stomach cave in toward my spine, to do my duty and sacrifice for the sake of holiness.

(If this sounds like the rhetoric of anorexia, well, keep reading.)

I made it through the night, the next morning, the next afternoon. Through hours of services, singing, breast-beating, and sermons. I was strong. I was proud. I was adult.

I was also very, very hungry.

In our house then, food was a kind of emotional currency. Food could be love or punishment; withholding of food could constitute either extreme. My mother was always dieting, which means that we ate, but always with the sense that we weren't really supposed to. The less you ate the better. Appetite was a bodily function that made you weak, and gluttonous, and fat. Appetite was to be squelched at every opportunity.

By 5 o'clock that Yom Kippur afternoon, I felt like I would faint if I didn't eat something. Anything. I left services and went around back, to the synagogue's playground (it was also an elementary school). I sat on the swing, went down the slide in my fancy new dress, and dug idly in the sandbox.

And that's where I found it: a half-eaten Milky Way bar. Someone had taken a few bites and then tossed it, wrapper and all, into the sandbox. It was food. It was my favorite candy bar. It was covered in sand and looked better than any food ever had to me.

I peeled the wrapper and took a bite of the uneaten side. I took another, and another, and soon had eaten the whole thing, sand and all. I felt guilty and ashamed. I was weak. I was unworthy.

I was also, later that night, sick as a dog, throwing up the candy bar and the break-the-fast meal we ate a few hours later. Retching and miserable, I had plenty of time to connect the dots: I had sinned, and I was being punished. Violently. Virulently. Righteously.

Fast-forward 35 years or so, to a night when my daughter Kitty was lying in the ICU, dying from anorexia. She was dying because she would not, could not eat. It took every ounce of determination and grief my husband and I had to help her start down the road to recovery.

That's when I connected the new set of dots: Not eating could kill you. Being hungry held no virtue. In the ultimate appetite sweepstakes, being hungry was the booby prize. You thought it was the goal, but really it was the punishment.

There have been plenty of times in my life since that Yom Kippur long ago when I have been hungry. But in the intervening years I've learned to honor my appetites--for food, for love, for compassion, for connection. This learning has changed my life.

And that's why I'll never again deliberately starve myself, for a day or for a month. There's far more virtue in learning to live with appetite and hunger than in shutting it down.

"You look great! Have you lost weight?"

I went "home" for the weekend last week--back to Madison, where I lived for 16 years. It was great to see old friends, neighbors, acquaintances, etc., and very emotional, too. It takes time, lots of time, to forge friendships. This year is rather a lonely year in Syracuse.

It was great to see those friends, but I really wish so many of them hadn't commented on my weight. The consensus seemed to be that I was looking better than usual so I must have lost weight. This conflation really, really bugs me. Why is a weight loss always associated with looking good?

I went to the doctor today and got on the scale for the first time in probably 6 months. Yes, I have lost a couple of pounds, but not, as one friend suggested, "a ton of weight!" For someone my size--five foot one and a little, 161 pounds--a couple of pounds makes little visible difference.

"You look good because you're happy," my husband pointed out. That's right. I'm engaged and invigorated by my new work and by the challenges and curiosities of making a home in a new place, and it shows.

I look forward to a day when looking good and losing weight are two separate and distinct ideas. And when we think twice before mentioning them in the same breath.

Celebrity weight watchers

I won't be the first person to rant about the intense media attention we pay to celebrities' weights, and I won't be the last. But this little video really bugged me almost as much as the scene in the Sex and the City movie where Samantha (Kim Cattrall) has gained 10 pounds, and the rest of the characters act like she should put on a burqa and have her jaws wired shut.

In this case, the video suggests that actress Demi Moore has gained 15 pounds. "Is there more of Demi to love?" croons the voiceover. The tone of voice makes it clear that this would not be a good thing.

I pity any woman (or man, for that matter) who is subjected to this kind of scrutiny. It feels to me like a form of externalized self-loathing--things we wouldn't dream of saying to or about an ordinary person may be said about a celeb because, hey, she's fair game.

We learn, from the culture that produces such relentless trash, to say these things to ourselves, about ourselves. Videos like this feed the nasty little voice that lives in our heads, telling us you're fat, you're ugly, you're old, you're worthless. For some of us, this voice can become deafening. For some, it stays relatively quiet.

But you know what? Even a whisper of this is too much.

Harvard bucks the mainstream on "nutrition information"

Last year, if you ate at a Harvard dining hall, you were confronted by a large sign listing the calorie, fat, protein, etc. content of everything you ate.

This year the signs are gone, thanks to a group of parents who protested them.

"The feeling was that for people who have eating disorders or who struggle with issues around the literal value of food, the emphasis on nutrition information does not always lead people to eat in a healthy manner," said Harvard dining hall spokeswoman Crista Martin.

It's naive of anyone to think that an "emphasis on nutrition information" will lead to "healthier" eating decisions. Most of us can't help but be aware of fat grams, calories, etc. in the food we eat (or don't eat), and the effect is hardly salutory.

I practice intuitive eating most of the time. I gave up dieting years ago. I parented a child through anorexia. But when I'm faced with those "nutrition information" signs, I immediately feel that whatever I'm eating, or about to eat, is too much. I immediately slip back into a mindset of any calories are too many.

It's like the story about the old miser and his horse. Each day the miser fed his horse a little less, until finally the horse died of starvation. The miser's comment: "Just when I was training him to need no food at all!"

Those calorie count listings make me feel as though the goal is to eat as little as possible--ideally, nothing. They immediately trigger fear, anxiety, and the restricting mindset.

Luckily I am too ornery to stay in that mindset for long. But is it really a surprise that for students at Harvard, one of the most competitive schools on the planet, signs listing calorie counts of everything served in the dining halls might be a bad idea? That a vulnerable population (driven, intensely competitive Harvard students) might be triggered by these reminders of "healthy eating"?

I don't think so.

I only wish the rest of the world would follow Harvard's lead on this one.

Free bulimia treatment

A research team at University of North Carolina, led by the fabulous Cindy Bulik, is looking for people with bulimia to take part in a pioneering study on treating this disease.

The study takes place at two sites: UNC, in Chapel Hill, and University of Pittsburgh. But you may not have to live in either of those places to enroll in the study, because half the study participants will be randomized to what researchers are calling CBT4BN, a web-based treatment involving weekly on-line chats with therapists and other distance elements.

The idea is to get treatment to people who may not have access to a therapist trained in cognitive behavioral therapy (CBT), which is currently the gold standard of treatment for adults with bulimia. The Maudsley approach has shown great promise for adolescents with bulimia.

Eating disorders are terrible, life-sucking diseases, and their treatment is still largely mysterious. Studies like this one are literally a lifeline to people struggling with EDs. So thank you Cindy, and the rest of the team, for doing this crucial work. Those of us who have seen people we love come suffer with an ED are very grateful.

Fighting weight discrimination, one doctor at a time

If you've ever had the experience of going to a doctor for an earache and being lectured on your weight--or even if you haven't had that experience but dread it--there's hope for America's doctors. Yale University's Rudd Center has created an online course to help sensitize docs to weight discrimination in themselves and in the health-care system. According to a spokesperson, the course is also designed to help docs develop strategies to serve their patients better--always a good thing.

Doctors get 1 credit of continuing ed for doing the course, and their patients get a doctor who's at least been exposed to the notion of fat acceptance and questioning the status quo on weight.

I looked at the first few frames of the course and have to say it looks pretty cool. Check it out. Better yet, get your doctor to check it out.

Fighting Stigma with Science

This video is required watching for anyone with an interest in eating disorders. Cynthia Bulik is one of the leading researchers in the field, and this interview, done by Jane Cawley, co-chair of Maudsley Parents, is compelling and important. Take a look.


Fighting Stigma with Science from Jane Cawley on Vimeo.

Eat to enjoy, not to lose weight

This article in the New York Times may seem a bit redundant to some, but I'm encouraged to see it in the venerable Gray Lady herself. It saddens me a bit that the notion of eating for pleasure rather than weight loss is such a novelty, but there it is. At least it's out there.

David Foster Wallace, 1962-2008

My closest encounter with the writer David Foster Wallace, who committed suicide last week, came when I was working as an assistant in a small literary agency. One of my jobs was to read the slush pile, the manuscripts sent in cold by hopeful writers looking for an an agent. One of the manuscripts that came across my desk was a draft of what later became Wallace's first published book, The Broom of the System. It was brilliant, entertaining, dazzling, and I wanted to take Wallace on as a client. My boss said no. "He'll never be a commercial writer," he said scornfully, and that was that.

He was wrong, of course, about that and many other things. Wallace went on to become not only critically acclaimed but to achieve some measure of commercial success. He was an original, one-of-a-kind, a writer of immense talent and heart. From the oustide, his life looked golden in every way.

He was also, we know now, severely depressed for much of his life. His struggle with depression came to an end last week when he committed suicide. And therein lies my point. It is impossible to know, from the outside, what anyone else's interior life is really like. That works both ways: The perfect-looking life may be a living hell, and the seemingly diminished life may be rich and full in ways outsiders can't imagine.

I bring this up not only because I'm mourning a writer of grace and heart; I bring it up in this blog because eating disorders, like depression, often present a golden exterior. The life of someone with an ED can look wonderful, perfect, fulfilling to an observer. Yet the person who struggles, every day, every minute, with anorexia or bulimia or ED-NOS, may be smiling through torment.

When I read about Wallace's death, I couldn't help thinking about how many people with anorexia wind up committing suicide as well. And I mourn them too--the lives that could have, should have gone a different way.

I mourn the misfire of chemicals in the brain that causes severe depression, anxiety, eating disorders. And I look forward to the day when we will know more and be able to help more.

In the meantime, go out and read one of Wallace's works, and remember this talented and tormented man.

No evidence-based treatment for anorexia?

According to this study, which is an overview of 40 years of eating disorders treatments, there are still no evidence-based treatments for anorexia nervosa. "A specific form of family therapy (based on the Maudsley model) appears promising," write the study's authors.

Appears promising? Actually, FBT, or the Maudsley approach, has been shown to be successful (85 to 90 percent long-term recovery rates) for treating both anorexia and bulimia. In the last 10 years there have been several good studies on FBT, including this one, this one, and this one.

And yet some of the top researchers in the field are still saying that there is no evidence-based treatment for anorexia, and that the Maudsley approach "appears promising." Which is rather like saying that there appears to be a link between smoking and lung cancer.

After 40 years with no other good treatments, you'd think researchers would jump on this one. So why the damning with faint praise?

Come on, you guys. You're the ones who can get the word out to parents best. You have a moral obligation to spread the word about FBT--the ONLY evidence-based treatment we've got at the moment for treating anorexia. I'll be thrilled if we turn up more treatments that are effective. In the meantime, though, let's use what we've got.

Take a survey, help eating-related research

The invitation below comes from a graduate student at the University of Maryland. Please correspond directly with her if you have questions. Take the survey and help add to what we know about eating.

--HB

TO ALL WHO WROTE IN: The link has been fixed now. Thanks for letting me know!

TAKE A SURVEY

Do you love food? Can you often “out-eat” most of your friends? If the answer to either of these questions is “yes,” you may be a great candidate to take my survey.

My name is Colleen Schreyer, and I am a grad student at the University of Maryland, Baltimore County. I am doing my master’s thesis on individuals who are able to eat a lot of food, and genuinely enjoy eating. I am also looking at individuals who are able to eat a lot of food, and perhaps don’t feel so good about it. I have an online survey that takes approximately 30 minutes to complete. All participants are entered in a drawing to win an Apple Ipod. Your answers are completely confidential, and I have approval from my university to conduct this research. If you would be willing to check out the survey, please click on thIS link. All and any help is greatly appreciated. If you have any questions, please email me- colleen2@umbc.edu. Thanks so much for your time!

An open letter to all diet food peddlers

Due to the recent avalanche of PR-type emails to my inbox, I feel compelled to write this letter.

If you do PR for a diet-related product, please do not send me emails offering to send me samples and hoping I'll review it on my blog.

Don't send me perky emails about 100-calorie foods that will fill you up all day, packed full of unparalleled nutrients. (Really! Who dreams this crap up?) Don't think I'll shill for you. I won't. If I write about your diet product, rest assured I will tear it apart. That kind of publicity you really don't want.

This blog is NOT diet friendly. To paraphrase my late friend Mimi Orner, we are anti-diet, anti-anorexia, anti-bulimia, anti-healthy eating fascism, and anti-eating disorder here. I am not your friend. My readers are not your potential customers.

This blog is a diet-free zone. Go peddle your crap somewhere else.