Usable Insight – The Anorectic in the ER
Children get their sense of well being from how much their parents like and enjoy each other
I just watched a very helpful and courageous episode of Katie where Katie Couric admitted her battle with bulimia in college and beyond.
I can’t prove the following, but it may speak to some of you, especially some of you with eating issues. A certain amount of a child’s — and later adult’s — well-being comes from how much their parents like and enjoy each other. Also conflict between parents is not as big a problem for the developing psyche of a child because conflicts are inevitable. The problem is when conflicts never get resolved and keep repeating themselves. Over time that “never ending” conflict and the simmering bad will just below the surface of parents toward each other can feel unsafe and disheartening to a child.
The reason for that is that for a child’s personality to feel solid, the child needs to feel that they are emotionally safe at home. When parents seem locked in conflict, children can viscerally feel that at any given moment, that what they are counting on to feel safe and secure, can explode and be gone in an instant. Sometimes children who feel out of control of what they need to feel safe from their inside out (i.e. the loving calmness in their home between their parents) will focus on things they can control on the outside. Eating disorders offers them such a focus.
With bulimia, they get to feel great — or at least immense relief — when they binge, and then they get to feel guilty, ashamed and beat up on themselves afterwards. Given the choice between feeling great and then feeling awful towards themselves vs. feeling the terror that the psychological ground (their home and the relationship between their parents) on which they are standing is shaky and about to totally fall apart, it’s easy to understand why they might choose the former.
Many years ago, I was working in the UCLA ER as the psychiatric resident on call. At that time, UCLA had one of the nation’s preeminent eating disorders program.
On this particular night I saw a young woman, I shall call Jenny, in her early twenties who had anorexia and weighed close to 85 pounds. She looked ghastly. Like many of the similar anorectic patients Jenny seemed to be a shell of a human being both physically and psychologically and to be nearly completely focused on her weight and need to exercise.
Also like many similar patients, her family had a high amount of conflict that had been going on for a long time that not coincidentally matched how many years Jenny had anorexia. To be fair to (vs. blaming) her parents and the parents of many of these frightened and frightening children, these parents’ understandable feelings of helplessness and fear for their child can manifest as being controlling of the child and angry (displaced) at each other which can add to the feeling of conflict that the child may be reacting to.
Something that anorexic and bulimic patients often have trouble realizing is how frightening they are to the parents who love them and how that can overpower their parents. It’s really difficult for the anorectic or bulimic patient to imagine so overpowering anyone when inside they feel so powerless. That can cause their parents to deflect their helplessness onto each other, thus increasing the conflict between them.
The ER was quiet that night and I had some time to spend with Annie while we awaited for her to be admitted upstairs to the in patient unit. As a psychiatric resident we had learned many approaches to treating a variety of psychiatric disorders. These included hypnosis and something called guided imagery where you would have a patient close their eyes and guide them through a visualization. I intuitively had an idea and asked Jenny if we might try something that might help her relax.
As best as I can recall, the guided imagery exercise went something like the following:
Jenny, get comfortable in your chair.
Close your eyes and begin to breath slowing, taking in a deep breath 1-2-3, and now exhaling 3-2-1.
Do that again, breathe in 1-2-3, breathe out 3-2-1.
Do it once more, breathe in 1-2-3, breathe out 3-2-1.
Now place your left hand on top of your stomach, right on top of your belly button.
Breathe in 1-2-3, breathe out 3-2-1 and feel the warmth from your left hand laying calmly on your stomach and calming your stomach.
Now imagine that that left hand is the hand of your mother comforting your stomach.
Feel her warmth going through into your stomach and radiating around the area surrounding her hand on your stomach.
Feel the connection of her left hand exactly in tune with your stomach as you breathe in and out and your stomach rises up and down as your breathe.
Imagine her left hand taking all your pain and tension away from your stomach.
Now place your right hand on top of your left hand and on top of your mother’s hand and imagine the right hand is that of your dad resting on top of your mother’s hand.
Imagine your father now saying to your mother and to you, “Everything is going to be okay, you’re going to be okay, we’re all going to be okay.”
As you feel your dad’s right hand on top of your mom’s left hand and both of them on top of your stomach, feel that you have a center deep inside you that feels warm, secure and safe.
Feel what that feels like and breathe in 1-2-3 and then breathe out 3-2-1.
Repeat that again, breathe in 1-2-3 and breathe out 3-2-1.
Now feel that your dad’s right hand on top of your mom’s left hand on top of your stomach is leaving you with a core and center and that you can now begin to move both those hands from your stomach and when you feel ready, begin to blink your eyes as you come back to where you are sitting and being in this room.
Within a few seconds, Jenny began to blink, smiled and yawned with only a slight sense of embarrassment. She seemed to be more like a person than an object or a thing. About this time people came down to say that Jenny’s bed was ready upstairs. She gathered her belongings together smiled at me and headed out the door. When she got there she looked at me and said, “Do you think it would be alright if I grabbed something to eat before I went upstairs?”
I smiled back at her and said, “I think we can arrange that.”
Thank you Katie for helping me remember this moment thirty four years ago.
Jenny wherever you are, I hope you are doing okay and happy.
Also:
- Los Angeles Times: A Breakthrough Moment for Us Both
- “Just Listen” Discover the Secret to Getting Through to Absolutely Anyone
- What Your Teenager Wants You To Know But Won’t Tell You
Tags: anorexia, bulimia, eating disorders
September 26th, 2012 at 9:47 am
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September 26th, 2012 at 9:37 pm
Someone commented on this post at Psychology Today with the following (I think their point is valid, although the point of my blog was not to blame the parents, which it certainly sounded like, but to provide a guided hypnotic experience to Jenny of being comforted by her parents from the loving people they were inside all the conflict they manifested on the outside that was triggered by their fear for Jenny):
Dear Mr. Goulston,
The field of eating disorder treatment has changed since you were a resident at UCLA 34 years ago.
For one thing, families are no longer blamed for causing, or contributing to causing, anorexia nervosa, bulimia nervosa, or other eating disorders. Your theory that parents play a role in causing anorexia or bulimia has been rejected on the basis of empirical studies that have been conducted during the past three decades. For example, the American Psychiatric Association states unequivocally that “No evidence exists to prove that families cause eating disorders.” APA, Practice Guideline for the Treatment of Patients With Eating Disorders (Third Edition)
http://www.psychiatryonline.com/pracGuide/pracGuideTopic_12.aspx (p. 26) The APA Guideline further advises that articulating theories that imply blame or permit family members to blame one another, or themselves, is not only inaccurate, it is therapeutically harmful. (p. 26) The best available empirical studies have shown that while some families of eating disorder patients are characterized by conflict, others are not, and that compared to other families in the community there are no significant differences and no causal link can be established.
Your vignette about “Jenny” is entertaining and makes a good story. However, there have been no scientifically valid studies showing that either hypnosis or guided imagery is effective in treating anorexia nervosa. For a complete review of RCTs see the study published by the AHRQ. “Jenny” may have gotten temporary relief from anxiety, but there is no study data, or consistent clinical experience, supporting either hypnosis or guided imagery as a primary treatment for either AN or BN.
The model of treatment that is now considered the gold standard for treating children and adolescents who develop an eating disorder before the age of 18 is the Maudsley model of Family Based Treatment, as manualized by James Lock of Stanford and Daniel LeGrange of the University of Chicago. In a randomized, controlled clinical trial published in 2010 in the Archives of General Psychiatry, M/FBT was shown to be superior to individual psychotherapy. In fact, no method of treatment has ever been shown to be superior to M/FBT.
September 26th, 2012 at 9:40 pm
Wow! This could be one particular of the most beneficial blogs We’ve ever arrive across on this subject. Actually Great. I’m also an expert in this topic so I can understand your effort.
September 27th, 2012 at 5:17 am
Dear “Someone from Psychology Today”,
It’s OK to disagree with him…but he’s still Dr. Goulston, not Mr. Goulston.
September 27th, 2012 at 12:29 pm
More input from the “Anonymous” at Psychology Today:
Subject: Mr. Goulston,
Your post is
Mr. Goulston,
Your post is filled with several comments about anorexia nervosa that are
simply myths.
First, you say that sometimes children who feel out of control of what they
need to feel safe, i.e. the loving calmness in their home between their
parents, will focus on things they can control on the outside. You claim that
eating disorders offer them such a focus. You are saying, therefore, that
people with eating disorders focus on their eating disorder because they can
“control” their eating disorder. This viewpoint implies that eating disorders
are a choice by the sufferer. The modern evidence, however, shows
convincingly that eating disorders, such as anorexia nervosa and bulimia
nervosa, are illnesses, not choices, governed by neurobiological processes
with a strong genetic component. People no more choose AN or BN than they
choose any other illness. To suggest that eating disorders are a choice
reinforces stigma. Moreover, that point of view leads professionals to see
sufferers as uncooperative when they are unable to eat, rather than as being
under the influence of a biologically-based disorder. This often leads to
ineffective and harmful approaches to treatment.
Second, you write that with bulimia, suffers “feel great when they binge.”
Where is the evidence for this? Most people who suffer from bulimia report
that they do not feel “great” about episodes of bingeing.
Third, you claim that parents of children who suffer from anorexia nervosa
experience “understandable feelings of helplessness.” While this may be true
for some, it is certainly not true for all. In fact, the modern methods of
treating AN and BN focus on empowering parents to take needed action. The
feelings of “helplessness” that some parents feel is largely the result of
the fact that misinformed eating disorder professionals have, for several
decades, blamed and marginalized parents for no logical reason. In today’s
era of improved treatment, on the other hand, which is very different from
when you were in medical school more than 30 years ago, parents are generally
given messages of empowerment and optimism, not helplessness. Not
coincidentally, rates of recovery have improved.
Fourth, you contend that the “fear” that parents sometimes experience often
expresses itself as anger. However, the best available scientific studies
have shown this to be a myth. Actually, the vast majority of parents show
remarkably low levels of anger when their child is suffering from anorexia
nervosa.
http://www.ncbi.nlm.nih.gov/pubmed/22072411 [1] By conrast, many eating
disorder professionals suffer from job burnout, which often does expresses
itself as anger toward patients who suffer from anorexia nervosa.
http://www.ncbi.nlm.nih.gov/pubmed/22072411 [2] This is all the more reason
why parents generally tend to be more effective than professionals are in
treating anorexia nervosa in children and adolescents who develop AN before
the age of 18.
Anorexia nervosa has a high rate of mortality. If not treated with an
evidence-based approach, it often leads to a lifetime of suffering.
Therefore, it is important that the public be given accurate information.
This is my “point of view,” and the reason for my comments.
[1] http://www.ncbi.nlm.nih.gov/pubmed/22072411
[2] http://www.ncbi.nlm.nih.gov/pubmed/22519896
September 27th, 2012 at 12:30 pm
My response to last post by “anonymous” at Psychology Today:
My P.O.V. is that high conflict in a home can “contribute” to the morbidity in many and possibly the majority of psychiatric conditions. I am not saying that it causes it. In fact the true causes for many conditions are not known, i.e. does neurochemistry and neuroanatomy precede psychiatric conditions or result when a predisposition towards a psychiatric condition is triggered by the environment.
You may find evidence based studies to disprove that, but day in and day out clinical experience both in my office and in the offices of colleagues I am in touch with counts for something from the environment that contributes to mental illness.
More specifically are you saying that environment has no place in the causation or contribution to mental disorders and that it is just an artifact?
At any rate I do appreciate your input and hope that readers will also appreciate it.
Please continue to offer input that will help readers be more fully informed.
September 27th, 2012 at 10:15 pm
More interesting post from anonymous at Psychology Today:
Mr. Goulston
Your opinion that high conflict at home can contribute to causing anorexia nervosa is speculative. If a patient appears in your office for treatment for AN, you have no way of knowing whether conflict at home contributing to causing the disorder. It is just as likely that the disorder caused the conflict at home, or that some third factor caused or contributed to both, or that the presence of both AN and conflict at home is a pure coincidence. People with AN, like everyone else, have been exposed to an almost limitless number of environmental factors in life before they typically develop AN during adolescence. For you to isolate one factor — family conflict — and identify it as contributing to cause, demonstrates an arbitrary and speculative approach.
At least two papers support my postion. One is a review of virtually all published studies into the causes of eating disorders. Jacobi, Coming to Terms with Risk Factors for Eating Disorders: Application of Risk Terminology and Suggestions for a General Taxonomy, Psychol Bull 2004, Vol. 130, No. 1, 19-65.
After reviewing 320 studies, the authors conclude that not a single study has shown that family functioning variables or family interaction styles can be classified as a causal risk factor. (p. 54) A second study was longitudinal in nature. Nicholls, Childhood Risk Factors for Lifetime Anorexia Nervosa by Age 30 Years in a National Birth Cohort, J. Am. Acad. Child Adolesc. Psychiatry, 48:8, August 2009. In that paper, 11,211 individuals and their families were studied from the time the individuals were born in 1970 until the year 2000, when they turned 30 years old. As expected, slightly less than 1% of the individuals (101) had developed anorexia nerovosa during their youth. When the researchers went back and looked at the data for those 101 families before the diagnosis of AN, however, they could find no factors that distinguished those families from the overall group. Specifically, the researchers wrote that the parenting style in those 101 families was indistinguishable from the parenting styles in the rest of the families. (p. 796) The advantage of the Nicholls study is that data was collected on the families over time, including before the individuals developed anorexia nervosa. This allowed the researchers to identify features of the families before AN. This protected against retrospective bias.
While clinical experience has a role to play with respect to some issues, it’s not clear that clinical experience is helpful if you are trying to determine the cause of a condition such as AN. For example, if a patient presents with autism, it is easy for a clinician to take a full history, determine that the individual had receive vaccines as a child, then conclude that the vaccines must have played a role in causing the autism. As scientific studies have shown, however, there is no causal link between autism and vaccines. A clincian’s bias will tend to see a causal link when there is none.
You were educated at UCLA more than 30 years ago. At that time, many of the professionals who worked in the eating disorders program at UCLA were guilty of clinicians’ bias. They tended to believe that parents play a role in causing anorexia nervosa. They offered no objective data to support their opinion. At least one has acknowledged (privately) that he was mistaken.
The most effective method of treating anorexia nervosa (FBT) takes an agnostic position on cause. After all, knowing the cause of an illness really tells us nothing about how to treat it. For example, nobody knows what causes childhood leukemia. Nevertheless, some very effective treatments have been developed for childhood leukemia. The same is true with respect to anorexia nervosa that develops during adolescence. We have effective treatments, most notably FBT. Maybe some day we’ll know cause. But today we don’t. My P.O.V. is that in the meantime we should not speculate, especially since the balance of the objective data tends to disprove the hypothesis.
September 27th, 2012 at 10:16 pm
Excellent information from anonymous at Psychology Today
Submitted by Mark Goulston, M.D., F.A.P.A. on September 27, 2012 – 10:11pm.
Thank you “anonymous” for educating my readers and me about the current status on eating disorders.
What would be your suggestion regarding my anecdote regarding Jenny, which did take place as described? And you’re right that there is not any indication that the exercise/intervention we did had any lasting value, especially since there was no continuation of anything like that during her course of treatment. It did seem to offer her some immediate psychological and emotional relief.
Do you think that using innovative techniques that are not evidence based that appear to provide relief from psychological and emotional pain should not be used?
I appreciate your speaking of bringing order and consistency to a field that as you say was not very evidence based thirty years ago.
I would however also add that just because something isn’t proven and isn’t evidence based doesn’t mean it is not useful.
Do you believe that no medicines should ever be used off label until it is proven by controlled and evidence based studies to be efficacious?
September 28th, 2012 at 2:09 pm
More from “anonymous” at Psychology Today:
You asked what I would have
Submitted by Anonymous on September 28, 2012 – 11:19am.
You asked what I would have suggested regarding the patient “Jenny.”
First, I would have asked her parents what they thought would be the best way of helping her regain weight and resume normal eating patterns. Thirty years ago, this was rarely done, because clinicians assumed parents were the problem, not the solution. However, the FBT empirical studies have shown the opposite. Generally, parents are highly competent in helping their offspring recover from anorexia nervosa. The central principle in the Maudsley/ FBT approach is that families are encouraged to work out for themselves how best to help restore the weight of their child with AN. See the randomized, controlled clinical trial comparing FBT with individual psychotherapy. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3038846/?tool=pmcentrez
The data from this experiment showed that when parents were placed in charge, the recovery rate was twice as high as when a professional psychotherapist was in charge using techniques of individual psychotherapy.
I’m curious whether you asked Jenny’s parents, therefore, 34 years ago, how they thought she could best be restored to normal weight and returned to normal eating patterns? I suspect not.
Second, if I were in that ER, I would have been reluctant to admit Jenny into the hospital, and would have done so for only a brief period of time, and only if she was seriously compromised, medically. The Gowers studies in the U.K. showed that prolonged inpatient hospitalization is generally no more effective in treating AN than outpatient care, while imposing signficant costs, financially and in terms of psychosocial development. Therefore, I would have been inclined to release Jenny to the care of her parents and gotten the parents in touch with a professional who would have backed up their efforts to refeed her and help re-establish normal eating patterns.
Beyond that, I have no problem with using guided imagery to reduce immediate anxiety. However, guided imagery does not appear to be a reasonable long-term solution to anorexia nervosa.
Finally, while you persist in claiming that the family’s emotional environment can contribute as a causal risk factor for anorexia nervosa, you really haven’t offered any objective evidence for that assertion. If you were correct, we would expect to see AN statistically clustered in families exhibiting high levels of unresolved parental conflict. However, the best available studies have shown that not to be the case.
The best available research data shows that if one sister in a family develops AN, the odds of her other sisters also developing AN is no higher than in the general population, except for the influence of their shared genetic inheritance. If you were correct that unresolved parental conflict increases the risk of developing AN, we would expect to see a higher rate among her sisters than in the general population. The data, however, simply doesn’t support the assertion. See, for example,
Klump, Genetic and Environmenal Influences on Disordered Eating: An Adoption Study, J Abnorm Psychol 2009 Nov; 118(4): 797-805 (genetic influences on disordered eating account for 59%-82% of the variance, while non-shared environmental factors (i.e non-family environment) account for the remainder.) http://www.ncbi.nlm.nih.gov/pubmed/19899849
Also, Klump, Genetic and Environmental Influences on Anorexia Nervosa Syndromes in a Population-Based Twin Sample, Psychol Med 2001 May; 31(4):737-40 (genetic factors accounted for 74% and non-shared environmental factors for 26% of the variance in AN syndrome) http:??www.ncbi.nlm.nih.gov/pubmed/11352375
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