Should Eating Disordered Patients Know Their Weight?

Doctors weigh their patients. Patients own their charts. For some sensitive people, knowing their weight is a trigger to disordered eating. As such, should doctors not weigh patients who could be prompted to re-start their disorder, or should doctors make a point of weighing eating disordered patients as a way of desensitizing them about weight? Once again, there is no answer, only strongly held beliefs which get promoted by “experts”. My opinion: the doctor should obtain consent for weighing the patient so that the patient can take control of his or her mental health. Blood tests, although certainly more expensive than weight checks, can give health information and so obtaining weight is not critical to medical care for these patients. On the other hand, eating disordered patients do need to heal and accept themselves and that includes accepting their weight. However, in the course of the illness, patients may be too sensitive to deal with their weight and so it might make more sense to avoid that trigger, if possible. Should the psychotherapist inform the primary care doctor about whether to weigh the patient? Maybe, but I would prefer that the therapist work with the patient directly so that the patient can inform the physician about whether it makes sense to be weighed. After all, eating disorders are so often about control, returning control to the patient, in big ways and in small ways, is a major step of healing the disorder, in that the more control the patient has in his life, the less important it is to control eating. Like all self-abusive behaviors, we have no clear path of intervention. We have to use our best guess. That is the state of the art. Big data does not help us here. I can live with that.

Binge Eating Disorder

 

DSM 5 has expanded our notion of eating pathology to include a diagnosis of binge-eating, a behavior that almost all of us have experienced from time to time, but as with all of mental health, when the symptom is both intense and frequent, then a diagnosis is made. Along with a new diagnosis, there is now FDA approved treatment for Binge Eating Disorder, Vyvanse, a stimulant medication, typically used for ADHD.    http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm432543.htm

Truth be told, I, and many of my colleagues have been using stimulants to treat bingeing for over 20 years, but now we have support both from the DSM 5 and the FDA. In other words, our treatment went from “off-label” usage to “on label” usage and so for my existing patients this means more security, and for new patients, this means more awareness that there are treatments available. The closet eater can now come out of that closet. This is an exciting step forward, although the concept is simple. Drugs which suppress appetite will suppress the gratification from bingeing. Medical health improves as bodies return to a normal weight range and mental health improves as the patient feels less shame and guilt associated with binge eating.

Since I normally discuss working from the inside out, it might surprise some of my readers that here I am talking about working from the outside in. In essence, both are important. If I could not prescribe medication to help people help themselves, then I would be limited in my toolbox. Likewise, if I could not explore psychodynamic concepts with my patients, I would be even more limited. Binge Eating Disorder is an example of how if we begin to change the behavior first, then we can then proceed to work on the inner workings of the mind which led to this type of self-destructive behavior. Medications change behavior, sometimes, and when we have that tool available, with minimal side effects, then I am happy to prescribe. As with eating, it is the extremes which are a problem, not the middle ground.

Why Cognition Only Goes So Far

http://www.latimes.com/news/opinion/commentary/la-oe-wood-neal-habits-dieting-bloomberg-20130809,0,5731193.story

“Habitual behavior implicates parts of the brain that have relatively sparse connections to other brain areas involved in conscious decision-making (willpower) and goal setting. In effect, our bad habits represent neural islands, pretty much cut off from our thoughtful planning. We really can be of two minds — knowing and wanting to do the right thing but also unconsciously driven by habits triggered by the everyday contexts in which we live. In other words, willpower has limited command over our habitual mind. On top of that, exerting it is arduous, unpleasant and hence typically short-lived.”

Behavior is multi-determined. We can know what to do and then not do it. This applies to eating, relationship choice, and career decisions. Today’s LA Times Op-Ed article about changing eating patterns by Wendy Wood and David Neal outlines this issue. Understanding the depth of the human brain allows us to appreciate the complexity of behavior change. Merely understanding that eating too much sugar is “bad for your health” does not address the other brain structures which trump this understanding. These other brain areas can be habit areas, where our brains work on auto-pilot, or they can be in deep emotional areas where we want immediate satisfaction at the expense of long-term problems. Our brain is in constant conflict with itself, thereby giving us conflict in decision-making. We must balance out routines that are familiar, with the anxiety of a new activity. For some, this anxiety is coded as excitement and so fresh experiences are constantly wanted. For others, the comfort of sameness is more important than a new adventure. For most of us, we seek a balance, but finding this balance is the art of living. How do we enjoy food, without eating to excess? How do we not use food, as an outlet for sensual gratification? Understanding the basics of nutrition does not address the deeper meanings we attribute to the act of eating. These “neural islands” as stated above, describe how a person can be at war with himself. Psychotherapy attempts to bring these islands together to form a continent of understanding and awareness. Behavior can change, but not quickly, and not without harnessing all of the factors that go into that behavior. Cognition is only one piece.

The Eating Dilemma….

Eating Anxiety

What do YOU eat for anxiety?

Re-Posting Since I Did A Repeat Performance: Teaching about Anorexia Nervosa

        “The young woman is looking for some sort of control over her life,” I say to fourth-year medical students, as a way to help explain the self-destructive behavior that might underlie Anorexia Nervosa. “What does she say when you ask her about how it feels to have control over her life by not eating,” an eager, soon to be primary care physician asks me. “Well, she would deny the experience. She would say that she does not have a problem; that her parents are overly concerned and they always have been. Her denial of her problem, stimulates a question about what is going on, on a deeper level of her brain. This leaves us, the clinician, to speculate that it is possible that on an unconscious level, there is a positive affirmation in her starvation, in her ability to control her bodily urges.” I say, wondering if these future physicians are looking at me glassy-eyed because they are tired or because I am not explaining the unconscious very well, or both. “So, what is a primary care physician supposed to do?” Another eager and enthusiastic fourth-year medical student, interested in Internal Medicine, asks me. “Well, as with so many complicated diseases, the primary care physician, needs to shepherd the patient through the health care system. The patient will need monitoring of her electrolytes, her weight, her blood pressure. She will also need to see a nutritionist, along with, a mental health provider. The primary care doctor needs to coördinate care; provide the patient with a “medical home,” the new buzz phrase. The student looks at me with recognition, maybe a little embarrassment that the answer was obvious, and yet because we are dealing with mental health issues, the clarity of the situation gets blurred.

      I am back to wondering my age-old question. Do medical students, our future physicians, need to understand human behavior? If so, what is the best way to teach them? If not, should their psychiatry curriculum be limited to psychopharmacology? My answer is clear. A major challenge in being a physician is to help people, help themselves. Understanding how patients get in their own way is critical to helping all patients stay on a good path. This seems both obvious and neglected.

The Dinner Decision

     Leora and Abe, both in their sixties, married for ten years, never know what to make for dinner. Both are fifty pounds overweight, yet both insist that they “hardly eat anything”. Each night, when they both come home from work, they stare at each other, in what sounds like an agonizing way, and after a few tense words they both grudgingly “put something together.” Leora would be happy with a bologna sandwich, but she knows that Abe would be grumpy if she did that. Abe wants a nice meal, but he says he is “too tired to think about it.” I wondered aloud, “what about making a book every week which says what you are having for dinner on each night? Then, you can make a shopping list accordingly.” Abe looks at me like I have made an absurd suggestion and he says “well, we have recipe books.” “No, I mean something more specific-a book which says Tuesday, November 2, 2010, lemon chicken, brocoli and roasted potatoes,” I say, knowing that this is not a brilliant idea, but I am curious to see how Leora and Abe will respond to the directive. To my surprise, Abe says “but I don’t want to do that, I want Leora to know what will make me happy.” I pause, pondering Abe’s remarkable comment. Then, I say to Abe “you and Leora are very different people and as such you have very different ideas about food and it is hard to come to terms with the idea that Leora does not mirror you in this way.” Abe looks at me with pain in his eyes. “I have a hard time accepting that,” he says, as if he has thought about this before. The dual meaning of food as both a physical and emotional nutrient stands out for me in this moment. Abe and Leora nurturing one another, like  with so many couples, is a deep and continual challenge.

Weight Watchers

  Theresa, seventy, fifty pounds overweight, the subject of Friendly Fire,https://shirahvollmermd.wordpress.com/2010/01/23/friendly-fire/, seeing me consistently for ten years, says “I don’t know why I resisted weight watchers for all these years. I am doing it now and it is the best part of my life.” “No kidding,” I reply, thinking over the numerous discussions we had about how she can help herself with her weight problem.  “I go there,” she continues enthusiastically, “and I feel like I have a loving family.” Fellowship, I think, is the strength of these meetings.

   Blue, fifty-three, a patient of mine for three years, seventy pounds overweight, refuses to go to weight watchers, saying “I know what to do, I just don’t do it.” “Yes,” I respond, ” but Weight Watchers can help keep you focused.” “Well, I don’t think so,” she responds, as if we are in an argument. Persuasion, the art of it, is not often my job, but sometimes I think about how people can help themselves if they become more open to new experiences. Pre-conceived notions, resistances, get in the way, and sometimes these resistances are more rigid; other times there is an opening. I recognize with Blue that the feeling of being in a fight signals that the resistances are strong in this moment. I wonder if Blue will be like Theresa, wondering ten years from now, why she did not go sooner.

   Like antidepressant medication does not help every depressed person, Weight Watchers is not  helpful for everyone with a weight problem. Yet, everyone with a weight problem could go once to see  how it feels; to see if they think it is worth their time and money. Having said that, I am mindful of the emotional risk of trying to lose weight; fearing that a failed attempt will just make things worse psychologically speaking. Like a child who does not study for a test so that he does not feel bad if he does not do well, many people with weight problems prefer to avoid their food issues, rather than chance feeling like a failure. Appetite suppressanst and/or liposuction can be attractive because with these interventions, it is the procedure that failed, not the person.

    Weight is so interesting to me-the obvious mind/body connection. The meaning of food, the meaning of eating, is so rich with conscious and unconscious experiences. Food is an personal experience, a family experience and a social experience. The value we place on eating, the types of foods, the portions of food are all driven by biology, culture and emotional states. How these three factors are woven together define our relationship to our body and to our mind.

    Theresa knew that she would feel better if she lost weight. She also felt lonely and food gave her comfort. Simplistically speaking, now that she has found comfort with her new “family” she has less of a need to comfort herself with large portions of food. I say simplistically speaking because on the one hand I know it might be more complicated than that, but on the other hand, I wonder if it is as simple as that. In other words, Theresa needed a “family” to motivate her to take better care of herself. For reasons that are not clear to me, she joined Weight Watchers at a time in her mental life where she was open to having a new “family”. By contrast, Blue is in a scared place, a closed mental space, such that she is not emotionally ready to try new ways to tackle her weight problem. How much I wait for her to open up in her own time, and how much I push her to reconsider her decisions is the art of my job. Seeing Theresa’s turn with her eating, along with a turn in her mental state, makes me want to push Blue a little harder. At the same time, maybe I should let Blue change the subject; maybe I should respect her resistance. Dilemma.

Taste Buds and Sensitivity Buds: A Hypothesis

This blog is part of my series on the Neurobiology of Behavior.

With Thanksgiving here, I am interested in the work of Linda Bartoshuk PhD, a Presidential Endowed Professor of Community Dentistry and Behavioral Science at the University of Florida. Her research, spanning three decades, has focused on the genetic variations in the perception of taste. Through studies of the disposition and the density of taste buds on the tongues of test subjects, Bartoshuk has divided people into three categories: supertasters, tasters and non-tasters. Supertasters, despite their name, are oversensitive to flavor and so prefer bland foods. Tasters are people who can develop a sophisticated palate, some of whom will become food critics. Non-tasters do not appear to care too much about food.

Bartoshuk’s work makes me wonder if people can be divided into three categories of feeling sensitivity. There is the supersensitive, those who are so vulnerable to feeling that they cope in the world by being emotionally flat. There are the sensitive types, who like food critics, can parse out different kinds of feelings in any given situation. Finally, there are the non-feeling types, who although they have feelings, they only feel feelings which are hammered in. They miss the subtlety.

Adding on, I wonder if  matching sensitivity types could help one predict the longevity of a marriage. The non-feeler would do well with the sensitive type, since they could help each other manage feelings to enhance their lives, but at the same time,  they could manage their feelings so that they do not get overwhelmed. Sensitive types would do well marrying each other also, but they would not do well with the supersensitive type who needs to maintain equanimity by denying his feeling state.

Looking at feeling states, as we look at taste, we could imagine that we come into this world with certain sensitivities and certain insensitivities. Understanding those innate sensitivities and insensitivities could help us make good decisions for ourselves and our loved ones. Many people learn about themselves intuitively, or from their family and friends. However, there are times when a person can no longer help themselves, and their family and friends are at a loss as well. At those times, the individual can reach out to a therapist, gain insight into their wiring and thereby reclaim their lives.