Questions
and Answers with Dr. Belfer
My Sister Is Using Ipecac
Bulimia and Alcohol
My Daughter Is Throwing Up
Preadolescent Weight Gain--Is It Normal??
Eating Disorders and Sexual Abuse
Dialectic Behavior Therapy for Severe Bulimia?
High School Wrestler with Eating Disorder?
What Is The Best Treatment for Bulimia?
New Eating Disorder Diagnosis
Out of the Hospital without a Plan
My Daughter Is Skin and Bones
Much Too Much Exercise
At a Loss without Pain Meds
What Is the Best Treatment for Anorexia Nervosa?
Did I Cause My Daughter's Eating Disorder?
Dear Dr. Belfer,
I'm 17 years old. My younger sister, 15 years old, seems different lately. She is always worried about how she looks, she spends lots of time every day in the bathroom, she isn't fun anymore. To top it all off, every few days I find an empty bottle of medicine in our shared bathroom garbage can. The label on the bottle says Syrup of Ipecac. I baby-sit and have seen Ipecac at some of the homes where I baby-sit. Isn't that supposed to be for when a young kid swallows something they shouldn't to help them throw up? What is my sister doing with it? My sister will never talk to me again if I tell anyone about this? What a bind!
Sincerely,
Sister in A Bind
Dear Sister in a Bind,
This is a tough situation! When misused, Ipecac is an extremely dangerous medication. You are right to be concerned, it sounds like your sister has a serious problem.
When someone is too worried about their weight and uses Ipecac at all, it almost always means they have an eating disorder. Ipecac, when used as prescribed, in small amounts only in an emergency situation when a small child has swallowed something t heir parents need to help them get up quickly, is safe. When used repeatedly, day after day, Ipecac is EXTREMELY DANGEROUS. Ipecac is an unusual medication. When used in extreme excess, the substance in Ipecac that makes it effective can accumulate in heart muscle. When used day after day, the body doesn't clear this substance from the heart muscle quickly. When this happens, the active substance in Ipecac can cause the heart muscle to break down. This can lead to DEATH.
It is most important that your sister get medical attention. She needs to be evaluated by a physician who both knows that she is using Ipecac to excess and is aware of its potential dangers. As hard as this is going to be, you need to share this information with a responsible adult who is able to follow through on getting your sister medical care. The obvious choice is your parents. Once they know, they may want to contact your sister's pediatrician or primary care physician to inform them and to determine how and where your sister should be evaluated. Remember, this is a MEDICAL EMERGENCY. It is possible your sister's primary care physician will ask that your sister be taken to a local emergency room, where they will probably check her heart function, find out how much of the active agent in Ipecac is in your sister's system, and have her speak to a mental health professional about why she has been using the Ipecac (the possibility of an eating disorder will be reviewed).
Hard as this may be, it is most important that you follow up on this information. A responsible adult needs to know that this is occurring so that they can help.
Sincerely,
Dr. Perry Belfer
Dear Dr. Belfer,
I've been controlling my weight in an unusual way for several years; whenever I eat more than I planned, or when I really overeat, I just get rid of it, I make myself throw up. I know I'm bulimic.
I'm not as comfortable with this way of doing things as I used to be when I was in college. I want to stop. But, I have another problem that I'm afraid is going to make getting better a lot harder. I think I drink too much; way too much. I go out to drink with my friends just about every night I can. I almost always drink until I'm drunk. I can't tell you the number of times I've gone into work with a hangover; but somehow, I get by. My boyfriend, who likes to party himself, told me he was worried about how much I drink.
So what do I do? How do I take on both of these problems?
Sincerely,
Double Trouble
Dear Double Trouble,
Congratulations for deciding to take these problems on! It takes a lot of courage to acknowledge and face your problems as you have done. You have already gotten over one of the hardest steps you will face in your recovery process.
That said, you do have your work cut out for you. Overcoming an eating disorder at the same time as a problem with alcohol can be quite hard. Excessive drinking is a problem in itself. When it is in combination with bulimia, often, the eating disorder is worse than it otherwise would be. Alcohol tends to disinhibit behavior. Most individuals with bulimia are desperately attempting to maintain control over their food intake; alcohol weakens that control and makes both bingeing and purging more likely.
For many individuals grappling with both bulimia and problematic drinking, both problems require some kind of simultaneous attention. One of the most effective components of this kind of treatment, is for an individual to participate in Alcoholics Anonymous. At the same time it is important to be followed both medically as well as in psychotherapy for the bulimia. The physician(s) following you needs to know about both the eating disorder as well as the alcohol problems.
In a situation like yours, it is probably best to see a psychotherapist with specialized experience in working with individuals with bulimia. Preferably, they would have some familiarity working with individuals with alcohol problems and comfort with AA.
It is usually recommended that an individual attend many different (at least three to five) AA meetings to make sure you find one or more with which you feel comfortable.
Best of luck in your path to recovery.
Sincerely yours,
Dr. Perry Belfer
Dear Dr. Belfer,
My 17 year old daughter is spending lots of time in the bathroom after every meal. When I ask her about it she says everything is fine, she just needs her privacy. On more than one occasion, when I went in there later in the day the bathroom was a mess. Water was splashed all over the place and there were signs of vomit on or near the toilet bowl. I'm worried (and quite disgusted).
Sincerely,
Disgusted and Worried Mom
Dear Disgusted and Worried Mom,
From what you describe, it sounds like you may well have something to worry about and you need to find out for sure. The behavior you describe sounds like your daughter may be self-inducing vomiting after her meals. This is common behavior when someone has an eating disorder.
You didn't say if your daughter was of normal weight or overly thin. If she is very thin, she may have anorexia nervosa with purging behavior. This is a potentially life threatening condition and requires that your daughter get a medical evaluation soon.
If of normal weight, your daughter may be dealing with bulimia nervosa or be purging for other reasons. This can also be quite serious and your daughter should see her primary care provider. You might want to begin by telling your daughter that you care about her and are concerned about her. Be direct, and tell her what you have found. Let her know that you are aware that eating disorders are quite common among adolescent girls and young adult women and that you are worried that some of what you have found suggests that she may have a problem. Most individuals with bulimia will respond positively to a gentle caring approach, but not all will respond immediately. If your daughter denies that there is any problem, you may want to turn to her (or your) primary care provider for advice. You may also want to request a referral to a mental health provider with expertise in eating disorders for you to talk with. I commonly see family members of individuals with an eating disorder to help them bring the eating disordered individual into treatment, to help the family member manage their own reactions to the symptomatic behaviors as well as to cope with the consequences of the eating disorder.
Many young women with eating disorders are extremely appearance-conscious and thus are very embarrassed by purging. These are often young women who have been highly affected by media (television, fashion magazines, Hollywood) images of how they should look and behave. Thus, they often think of themselves as disgusting because they purge. A gentle, caring approach can often be very effective at drawing out a young woman to seek, or at least agree to, treatment.
Keep at it. This can be tough at first, but a gentle, caring consistent approach will generally pay off.
Sincerely,
Dr. Perry Belfer
Preadolescent Weight Gain--Is It Normal??
Dear Dr. Belfer,
My 11 year old daughter is getting a bit "pudgy." This last year, she has put on 5-10 pounds and looks very mildly overweight; actually maybe she just looks more "solid" than she used to. I remember when I was her age, I put on a little weight too, just before my menstrual cycles started.
Well, my sister and her family recently came to our house for a visit. My sister, who has always been very weight conscious, was totally blunt with my daughter. She just said, "This is NOT GOOD. Here you are, about to become a teenager, when social life is very important and you are getting FAT. You have got to do whatever it takes to get those pounds off PRONTO." Then my sister laid into me, "What kind of a mother are YOU? Letting your daughter gain weight at such an important time in her life! Don't you care about her social life? She'll hate herself forever." She just "lit into" me.
No need to say, my daughter was devastated; and so was I. My sister does tend to come on a bit strong sometimes, and I did defend my daughter, but I'm worried. Could my sister be right? Am I just ignoring reality? Am I setting my daughter up for social failure? I think I might be worrying too much, but I'm not sure. What do you think?
Sincerely,
Devastated Sister (and Mother)
Dear Devastated Sister,
Your sister comes on more than "a bit strong." Of course, I have no idea what her concerns are about weight, but her comments to your daughter were DEFINITELY NOT HELPFUL. Even if your daughter were mildly overweight, which is doubtful from your description (more later on this), hers would not ever be a recommended approach. All too many young women have gotten such feedback at a vulnerable time in their lives from relatives, friends, and even, sad to admit, health care professionals. All too often, the result of that feedback is diminished self-regard, negative body image and powerfully mixed feelings about maintaining a healthy body weight and life-style. For some, this is even the beginning of a lifetime of body disparagement and weight cycling (AKA yo-yo dieting).
I am not suggesting that you should be prematurely worried about any permanent effects of your sister's unhelpful comments. It is still certainly quite possible to undo the damage. You just don't want to compound the initial hurt.
Mild weight gain prior to the onset of menstrual cycles is absolutely NORMAL and biologically useful. The developing preadolescent's increase in body fat is what enables her to physically develop into a young woman. Basically, no body fat, no period. This is certainly oversimplified, but I think you get my point.
It may be useful to have your daughter hear this directly from her pediatrician or other health care providers as well. You will want to talk with your daughter directly about your sister's comments. Again, why she made such comments I have no idea. But whatever the reason, it is your sister's problem, not your daughter's. You may want to emphasize the importance of her body's changes, as you would in any mother-daughter talk about the onset of adolescence and menses, and the fact that the body needs the extra weight right now to make the changes that are in process.
With regard to the social issue, it is a real one, but less severe than your sister portrays it. As your daughter develops into a young woman, her body will no longer need to maintain those extra pounds (relative to height) and all will even out. If your daughter wants to take any action at this point, it would probably be to just make sure she is developing somewhat healthy eating habits (a tall order for adolescents these days, male or female) and getting some regular exercise.
Sincerely yours,
Dr. Perry Belfer
Eating Disorders and Sexual Abuse
Dear Dr. Belfer,
My younger sister, who is 22 years old and in college, just disclosed to me that she has had an eating disorder for several years. Apparently she binge eats and then avoids gaining weight by throwing up afterwards. She diets like mad all the time; she's been doing that since she was 14 years old.
I heard that almost everyone with an eating disorder has been sexually abused. Does that mean my sister was a victim of sexual abuse? I would hate to think that had happened to by sister, she denies it, but does that mean she just doesn't remember?
Sincerely,
Perplexed Sister
Dear Perplexed,
I can certainly understand your confusion, especially given the common idea in the eating disorders professional community about a decade ago that sexual abuse was extremely frequent in individuals who developed an eating disorder.
We now know, that just because an individual has an eating disorder does not necessarily mean that they have been subjected to sexual abuse. Thus, unless you have other information to the contrary, there is no reason to suspect that your sister has either been subjected to sexual abuse or has forgotten such an experience. Research to date shows us that eating disordered individuals are no more likely to have suffered sexual abuse than other individuals with different kinds of mental health problems.
That said, I would be remiss, if I didn't also note that the rate of sexual abuse in the general population of individuals with mental health problems is appalling. Thus, it is certainly common enough for individuals with an eating disorder to have suffered sexual abuse. It also appears that the more severe the eating disorder symptoms, for example, among those individuals who require either inpatient medical or psychiatric hospitalization for their eating disorder, the more likely is sexual abuse to have been a part of their earlier experience.
By the way, I'm glad your sister was able to disclose her eating disorder to you. That may be an important step in her recovery. I hope she is also getting treatment; bulimia nervosa is often quite responsive to treatment. Most often such treatment would include being closely followed by a primary care physician who knows she has an eating disorder, working with a mental health professional who is familiar with treating individuals grappling with eating disorders, as well as possibly seeing a nutritionist.
Sincerely yours,
Dr. Perry Belfer
Dialectic Behavior Therapy for Severe Bulimia?
Dear Dr. Belfer,
My daughter, Kathy, has a very bad eating disorder; she has been through hell. In fact, her father and I, her sister and brother have also been through HELL! Since she was a teenager Kathy has binged and purged, starved and gained large amounts of weight in endless repetitive cycles. She says can't break out of the cycles. Now my daughter is 29 years old and this has been going on for almost 15 years.
The eating problem isn't all of it, either. Kathy is terribly sensitive to everything that happens in her relationships. If a boyfriend slights her, sometimes she goes into a tailspin and her eating goes way out of control; other times she gets suicidal and tries to hurt herself. I can't tell you how many times she has been hospitalized on psychiatric units. She's depressed and moody all the time, and often she can be unbearably difficult to be around. But I know she doesn't want to be like this. She tells me she feels like her feelings are just out of control all the time. She means well, but can't seem to do any better.
Over the years, Kathy has been through every imaginable treatment; her father and I have spared no expense in getting her treatment, and luckily, she has had the best insurance. Kathy has been on specialized eating disorders units for months; she has been on a pharmacy's worth of different medications; she has seen therapist after therapist. I can't tell you how many times she has been disappointed. She always starts out hopeful but her feelings and her life don't really ever change.
During her last psychiatric hospitalization, she was seen by a consultant who told us there was this new treatment, Dialectic Behavior Therapy, that might help her. What is this treatment? What can she expect? Will it help my daughter?
Sincerely,
Mother In Hell
Dear Mother In Hell,
You and your family have been through hell. Your daughter is clearly among those eating disordered individuals who have benefited least from most well studied treatments, including both methods of psychotherapy as well as medication. Given the situation you describe, it is quite understandable that it has been recommended that your daughter enter a treatment program that offers Dialectic Behavior Therapy (DBT).
Dialectic Behavior Therapy (DBT) is a relatively new treatment, a form of Cognitive Behavior Therapy, developed in the 1990's by Dr. Marsha Linehan, a psychologist at the University of Washington in Seattle. Linehan has some very intriguing initial research results in the use of DBT with individuals with Borderline Personality Disorder. Individuals who suffer from this condition often have intense and unstable relationships, experience intense, labile moods, have an uncertain sense of personal identity and engage in self-destructive behaviors. Recently, DBT has also been utilized with individuals with severe relentless eating disorders, like your daughter's, as well as individuals with severe substance abuse problems. Often, as with your daughter, DBT is recommended for individuals who also experience multiple other problems in living in addition to their eating disorder.
DBT differs from other forms of Cognitive Behavior Therapy in very significant ways. From a DBT perspective, many of the symptoms and behaviors seen in both severe eating disorders and borderline personality disorder can be understood as a response to emotion dysregulation. Individuals who otherwise often appear to be quite competent in their day to day lives, lack skills to manage strong feelings and the situations that may lead to those feelings. Thus, a major focus of treatment is training in affect management skills. These skills include enhancing problem solving abilities, communication skills in stressful situations, assertiveness, facing problems as opposed to avoidance, tolerating distress, as well as identifying and labeling emotions. A core skill group is "mindfulness:" learning to observe, describe and participate with awareness as well as take a nonjudgmental stance, focus on one thing in the moment and doing what works (being pragmatic). Clearly, there are many complex skills being taught.
DBT treatment is typically administered in both group therapy and individual therapy formats simultaneously. Thus, the treatment is quite intensive. It is not known whether less intensive forms of the treatment (only group or only individual treatment) can be effective; so far it looks like the whole treatment package is needed for it to work. DBT requires a highly trained treatment team to deliver the parts of the treatment package together in a coordinated manner.
For individuals who feel out of control and whose multiple contacts with the healthcare system have often felt unsatisfactory, the DBT therapist's highly pragmatic stance of "radical acceptance" of the person's feelings and situation can be quite refreshing. On the other hand, DBT is very hard work for both the patient and the therapist.
Given the complex, painful history of your daughter's eating disorder, based on the information you have provided, it sounds like DBT might be a very reasonable treatment option. If you have difficulty accessing a trained DBT treatment team, you might want to check out Linehan's website at http://www.behavioraltech.com.
Best of luck to you, your daughter and your family.
Sincerely yours,
Dr. Perry Belfer
High School Wrestler with Eating Disorder?
Dear Dr. Belfer,
My son is on the high school wrestling team and he recently told me and his mother some things that have us very worried. It seems that his coach said that my son had to make sure he made the weight class below his actual weight and that he had to do "whatever it takes" to make that lower weight. What worried my wife and I even more was the things our son tells us the other guys on the team are doing to make their weight class: one of his best friends starves for several days before his weigh-in to make sure his weight is low enough. My son tells us that as soon a his friend gets weighed he goes out and eats everything in sight, sometimes so much that he finds himself throwing up. His friend also will wear layers of sweat shirts and pants and run up and down the stairs at the high school, until he sweats so much that he is certain he will make his weight class.
How worried should I be about all this?
Sincerely,
Concerned Dad
Dear Concerned Dad,
You did exactly the right thing sending in your query; you have every reason to be quite concerned as well as angry that the coach is putting such pressure on the kids on his team.
While 90-95% of persons who get diagnosed with bulimia nervosa are women, a significant number of current and former male athletes also develop this eating disorder. High school and college athletes who compete in sports with weight classes are at highest risk. Just like your son, high school wrestlers commonly experience pressures to establish or maintain an unrealistically low weight. Other male athletes include rowers, skaters and gymnasts. Among female athletes we see increased rates of eating disorders among all of the above sports as well as ballet dancers.
Basically, it is very important that you express your concerns directly to your son, and help him to see that his long term physical health is the priority. Bulimia Nervosa is nothing to fool around about; there are significant medical risks and some individuals die.
In addition to supporting your son in taking good care of himself, it will be most important for you (and perhaps other concerned parents) to talk to the coach. Most coaches are reasonable people; when appropriately informed they will adjust their behavior. If your coach is not one of these reasonable people, you will want to take your concerns up the administrative ladder in the athletic department and, if needed, to general school administration (e.g. principal, headmaster, etc).
Good luck!
Sincerely,
Dr. Perry Belfer
What Is The Best Treatment for Bulimia?
Dear Dr. Belfer,
I am 28 years old, and I've finally admitted that I'm bulimic! I told my personal physician, and she and I have been talking about plans for getting help stopping the bingeing and purging. I'm well educated, and usually think of myself as able to handle difficult situations and make well-reasoned decisions; I do it all the time at work. I have done well professionally, and have the means to get the best outpatient treatment available.
Well this one has me stumped. I decided to be really careful and have, with my doctor's help, sought several consultations about my situation, for recommendations for treatment. Now I have much more information than I can use. I saw three different consultants, and got three totally different opinions on how I should proceed.
First, I saw a psychiatrist, with expertise in psychopharmacology. He recommended taking medication. Second, I saw a psychologist with expertise in cognitive-behavior therapy who recommended that treatment. Then I saw a psychoanalyst who insisted it was critical for me to deal with the root causes of my problem. They can't all be right! What goes on here?
Sincerely yours,
Bingeing on Treatment
Dear Bingeing on Treatment,
First off, congratulations on acknowledging you have an eating disorder and going to talk with your personal physician about it! This is the most important single step you could have taken. You are not alone in your difficulty coming to this point: experts in the area of eating disorders have long known, through research first done in the 1980's, that while bulimia most often starts in an individual's late teenage years, most people don't seek help until they are in their twenties, just like you.
The dilemma you find yourself in, attempting to sort out conflicting treatment advice, implies that you have available to you an embarrassment of riches in possible therapies. The difficulty, as you know, is sorting out the possibilities.
I should acknowledge my biases as I answer your question: I am primarily trained as a cognitive-behavior therapist, with some psychodynamic background, especially with regard to treatment for eating disorders. I have spent much of my professional career in hospital settings, so I work closely with psychiatrists with a psychopharmacologic perspective. I have a major commitment to recommending empirically validated treatments, those that have been shown to be effective in clinical research.
That said, there are several treatments that fit the bill as
supported by the clinical research and that make sense as a way to begin. Dr.
Christopher Fairburn, of
Some key aspects of the CBT approach to overcoming an eating disorder include:
• Recording in detail all eating at the time
that it occurs, together with relevant thoughts and feelings
• Introducing a pattern of regular eating, thereby displacing many binges
• Using alternative behavior to help resist urges to binge
• Receiving education about food, eating, shape, and weight
• Introducing avoided foods into the diet and gradually eliminating other forms
of strict dieting
• Developing skills for dealing with difficulties that might otherwise trigger
binges
• Identifying and changing problematic ways of eating
• Considering the origins of the binge eating problem and the role of family
and social factors
Interpersonal psychotherapy, a shorter term variety of psychodynamic treatment, has also been shown to be effective in clinical research studies. As it's name implies, this treatment deals with interpersonal relationships as they relate to the bulimia.
Medications can also be quite helpful, and have been shown to be effective in reducing both the frequency and the urge to binge eat. By and large, the medications used for these purposes are the same antidepressant medications, often selective serotonin reuptake inhibitors (SSRI's), used to treat depressive and anxiety disorders. Interestingly enough, these medications have been shown to be helpful even if the individual is not particularly depressed or anxious. They appear to impact the urge to binge and purge directly. The primary dilemmas with medications are, that if you don't change your basic dietary patterns and beliefs about foods and body weight while you are on the medications, you will tend to relapse when the medication treatment ends. Thus, generally, medication alone, is not usually recommended as the sole treatment for bulimia. Some of the major exceptions to this rule are situations where either highly trained CBT or interpersonal psychotherapists are not available, economic means may not exist to pay for treatment (and health insurance, which generally pays for treatment, is not available either), or the individual is unwilling to enter into cognitive behavioral, interpersonal or other psychotherapy. Of course, if you also suffer from a significant depression or anxiety disorder, medication may be a key part of your treatment.
I would not mean to slight psychoanalytic treatments by my earlier comments. These treatments are generally not the first line of approach when an individual presents for treatment of bulimia. But even here, there may be exceptions. If the case is extraordinarily complex, if there are multiple other symptoms or conditions (e.g. impulse control problems, and either depressive or anxiety disorders, etc.) psychoanalytic treatment might be recommended early on. Recent specialized forms of psychoanalytic treatment, often from either a feminist, self-in-relation, self-psychology or object relations perspective might be recommended.
A newer treatment which has received some encouraging research support, is Dialectic Behavior Therapy (DBT). Developed by Dr. Marsha Linehan at the University of Washington in Seattle, DBT focuses on the same complex, multisymptomatic cases of bulimia as the varied psychoanalytic approaches. Time will tell whether DBT treatment will be shown to be as effective with severe bulimia as it appears to be with other complex conditions.
This has been a very long answer to your complex dilemma. I hope it provides you with useful information as you make your decision.
Sincerely yours,
Perry L. Belfer, Ph.D.
Dear Dr. Belfer,
I'm the mother of a 17-year-old daughter. Her new doctor just told my husband and I that our daughter has an eating disorder and needs treatment. We're totally freaked out. How could this happen to our baby? We've got two older kids who seem to be OK; where did we go wrong? We know they always blame the parents; maybe it's true, we must have done something really wrong. Did we cause it?
What does all this mean? Is she going to die? What does she need now? How can we help?
Sincerely,
Totally Freaked Out
Dear Totally Freaked Out,
The most important thing you can do right now is to attempt to calm your anxiety and to be supportive to your daughter. One thing is certain, SELF-BLAME DOES NOT HELP. She needs guidance in how to go forward from here, and help in taking the steps needed to move toward recovery. In all likelihood, your daughter is going to have to enter a process of treatment that may be difficult for her. She will likely be seen more frequently by her primary care physician (family doctor, pediatrician or internist), referred to a psychotherapist who specializes in eating disorders, and perhaps to a psychiatrist and to a registered dietician. For an adolescent, even following through on such a treatment plan may require lots of gentle support and encouragement from her parents.
The news that a child is suffering from an eating disorder often comes as a shock to families. It is possible that you and your husband may benefit from some support as well, as you help your daughter to enter into a process of recovery. In my own practice, I commonly see family members of eating disordered adolescents in exactly the situation you find yourself. Seeing a family therapist with expertise in eating disorders, for one or more sessions is often very useful. Mobilizing your own supports, family, friends, clergy and so on, may make the difference between a relatively smooth and rapid process of recovery and a more difficult one.
In all probability, your daughter's primary care physician, will serve as the leader of the treatment team, helping to guide you to useful referrals and answering questions that you have. It's very important that you use them as a resource in the early stages of recovery; as things progress and a treatment team emerges, it will be important for you to find out who to go to with your questions. Like any parent in this situation, you have lots of questions and worries, which need to be addressed in the context of your daughter's medical situation and your specific family context.
Often the hardest thing for families to manage at this point is avoiding focusing too much on food. When a child is dealing with anorexia nervosa, the self-starvation syndrome, parents and siblings often find themselves trying to "feed" the anorectic; with individuals grappling with bulimia nervosa, the binge-purge syndrome, family members may find themselves going through all kinds of gyrations trying to track how often their daughter purges, either by self-induced vomiting or use of laxatives. It almost never helps to be trying to count every bite your daughter eats or standing outside the door when she uses the bathroom. These behaviors generally lead the adolescent to rebel, often making the symptoms worse. Given how hard it is not to do these things, family counseling can be helpful.
As for your other questions, when treatment is initiated promptly, and family is able to be supportive, we generally have every reason to be optimist about outcome. Specific predictions of outcome are sometimes difficult to make, but once your daughter is fully engaged with her treatment team, you will want to talk about how she is doing, and her likely future course, with her psychotherapist and (if she is working with one) her psychiatrist.
Sincerely,
Dr. Perry Belfer
Out of the Hospital Without a Plan
Dear Dr. Belfer,
My 16-year-old daughter was just discharged from the hospital for an eating disorder.
She was on a specialized eating disorders unit far from our home for two weeks. When she was admitted to the hospital we were terrified; our beautiful accomplished daughter weighed just 87 pounds (she is 5' 5" tall). To tell you the truth, her mother and I were relieved when she was admitted, given how exhausted we were by the constant battles with her over eating. We even found "leftover" evidence that she was throwing up in the bathroom (at least one to two times per week). Ugh!
Now our daughter is back home with us. She seems much better, so far, but she is still pretty thin. Now she weighs 93 pounds. The hospital staff told us that her doctor and insurance company decided she was ready for discharge, with outpatient treatment. She did stop vomiting while she was there and she does seem to be eating some now; there are only a few things she eats, in small amounts, but at least she does eat those things.
The biggest problem is that given how far away the hospital is from our home, the hospital left us with the job of finding outpatient treatment for our daughter. What should we do now? What if she goes back to the way she was before? Right now we have no help at all.
Sincerely yours,
Father with Daughter Out of the Frying Pan into the Fire
Dear Into the Fire,
There are a number of things that may be helpful to you, both in terms of general support as well as specific recommendations on what to do next.
First, general support:
1. There are a number of very useful self-help groups for individuals and their families grappling with an eating disorder. One very useful such organization, that may be able to connect you with local support resources is the Anorexia Nervosa and Related Disorders Association, whose website may be found at http://www.anad.org.
2. A very useful book for families is "Surviving an Eating Disorder: Perspectives and Strategies for Family & Friends " by Siegel, Brisman and Weinshal (Harper and Row, 1988, Revised February 19 1997).
Next, more specific recommendations:
1. Primary Care Medical Care: Your daughter needs to have a primary care physician (e.g. internist, family medicine specialist, pediatrician, general practitioner) who is familiar with working with eating disordered individuals and is willing to work with you and your daughter. Often, young women at your daughter's current weight will need to be seen with some frequency by the Primary Care Physician (PCP). This might be as often as once per week or every other week. Your daughter's PCP will advise you on this issue.
2. Mental Health Care: I can give you general guidance here. You will need to find a mental health provider (typically a psychologist, psychiatrist, social worker or licensed mental health counselor) with specific expertise in working with eating disordered individuals and their families. Your PCP may be quite helpful here; in fact, if they have a specific recommendation, your daughter, you and your wife will want to see them first. This is because your PCP may need to work closely with the mental health provider. Establishing a treatment team whose members are already comfortable working together is very helpful.
If your PCP does not have a specific recommendation, ask how they would suggest you go about finding an eating disorders "expert." Contacting local or state professional societies can help here (e.g. the state affiliate of the American Psychological Association, American Psychiatric Association, National Association of Social Workers).
Your daughter may require individual psychotherapy, group psychotherapy or both. The mental health provider will advise you after an evaluation.
3. Therapy would be useful in your situation, families often find it helpful to have someone they can meet with to discuss and get advise on how to manage the stresses of living with an eating disordered individual and how to respond to specific problems. You may want to ask your daughter's mental health provider for a recommendation.
4. Nutritionist: A nutritionist/Registered Dietician who is highly experienced in working with eating disordered young women may be invaluable. This referral should come from either the PCP or mental health provider.
5. Case Manager: Often insurance companies will have case management services available for individuals who have been hospitalized for an eating disorder. You may want to contact your insurance company to find out about this useful service.
Finally, while this sounds complicated, treatment is generally covered by health insurance carriers and outcome for adolescents is actually quite good (with treatment). Stick with this and use your PCP and available mental and physical health providers as supports.
Sincerely yours,
Dr. Perry Belfer
Dear Dr. Belfer,
My 14 year old daughter looks like skin and bones. She seems to spend half her day staring at teen magazines and pictures of supermodels complaining about how fat she is. We argue every night at the dinner table about how little she eats. She never has more than a little watered down orange juice for breakfast and her friends tell me she never eats lunch at school at all. My little girl seems to be losing weight rapidly and I am terrified. From what she tells me, she lost her menstrual cycle five months ago. Three months ago, when the weight loss began, I took her to the pediatrician who said my daughter was under some stress but not to worry. My husband doesn't seem to think there is a problem. I'm too embarrassed to bring her back to the doctor because everyone will say I'm an overly worried mother. What should I do?
Sincerely,
Embarrassed and Worried Mother
Dear Embarrassed and Worried Mother,
Trust your own good judgment and don't worry about what anyone else tells you on this one. From what you describe, it sounds like your daughter has a very serious problem. She needs to go back to the pediatrician as soon as possible for a thorough medical evaluation. Other potential causes of her rapid weight loss need to be ruled out. If you have any difficulty quickly getting an appointment with the pediatrician, make sure to tell the office staff that the problems your daughter was evaluated for three months ago have gotten worse and that her food intake has dropped off a lot.
When the pediatrician sees your daughter, if they don't find another cause for the weight loss, they should refer you to a mental health professional with expertise in eating disorders. If this does not occur, ask for such a referral directly. Ask the pediatrician how serious the problem is; it doesn't usually happen on first evaluation, but sometimes an adolescent will need to be admitted to the hospital for medical treatment of the consequences of an eating disorder.
If other medical causes of weight loss are ruled out, there is a possibility that your daughter may have or be on her way toward anorexia nervosa. This is an extremely serious eating disorder which requires active treatment. Often treatment may include your daughter being seen in individual treatment by a psychologist, psychiatrist, social worker, nurse or counselor. Members of the family may need to be seen by the same or a different clinician, as dealing with anorexia at home can be challenging. Other treaters may be called in as well, most commonly a nutritionist. While anorexia nervosa, if that is what your daughter is dealing with, is very serious, it is also quite treatable. Active treatment for adolescents with anorexia is often highly effective so stick with it.
Sincerely,
Dr. Perry Belfer
Dear Dr. Belfer,
Over the last few months my college roommate has gradually increased her exercise routine from about 45 minutes of aerobic exercise per day to two and one-half hours per day. In the morning she has to go out for at least a one hour run. Every evening she goes to the gym for an aerobics class and then spends another half hour, at least, on the stairmaster. She always wants company at the gym so I always end up with her for her stairmaster time.
While she keeps up with her schoolwork, she neglects most of our mutual friends and never seems to get together with them anymore. How could she? She has no time! She's a great athlete but this is way out of hand. I don't know how to talk with her about this. Help!!!
Sincerely,
Prisoner of the Stairmaster
Dear Prisoner of the Stairmaster,
What a loyal friend, going with her for stairmaster time every evening! Loyal, but perhaps not ultimately helpful to either of you. The situation you describe is not an unusual one, and it can be difficult to get out of.
First off, it sounds like you do need to find a way to talk with your friend, at least to bring up your concern that she is exercising too much. There are many reasons why she might be doing this, and almost all of them are not good ones. Assuming for the moment that your friend is not in training for an athletic competition or event, since you didn't mention this in your question, your friend is exercising compulsively. This may be a sign that she is trying to avoid dealing with some painful thoughts or feelings, she may have some variant of Obsessive-Compulsive Disorder, a common and usually very treatable condition, or she might have an eating disorder.
Given that you are college students, it is slightly more likely that an eating disorder is the problem, as you are at a high risk age and in a high risk setting for the development of this condition. In any event, the best course of action is likely to be the same. Once you have expressed your concerns to your friend, if she is not able to get her exercise routine within more normal limits you would be well advised to speak to someone in the college mental health counseling service or health service about the problem. Given how common these problems are, it is likely they will be quite experienced in helping your friend. If this seems like too big a step, and you are in a dorm, you might want to speak to the dormitory resident assistant, and they can either make helpful suggestions or take over from there.
It might be helpful to make sure you have someone to talk with as well. Have you confided in your parents or friends?
If you would like to, or if this situation is causing you significant distress, or if you are simply unable to say "no" to your friend, most college counseling services are quite experienced in working with roommates in difficult circumstances. You might want to go in yourself to talk with someone about how to handle this tough situation.
Good Luck! And remember to take care of yourself in this situation as well as trying to take care of your roommate.
Sincerely,
Dr. Belfer
Dear Dr. Belfer,
I have been taking a narcotic called Vicodin for about 2 years. It started with severe arthritis in both hands. This drug helped immensely. Then I injured the nerves in my spine. I went through 4 spinal block injections which did nothing. The only drug that helped was the Vicodin. My doctor increased the dosage from 3 tablets to 4 tablets a day. Now he wants to stop my medication and I'm at a loss as to what to do. I'll have to go back to the arthritis pain and even worse the spinal nerve pain. What can I do?
At a Loss
Dear At a Loss,
Your situation is unfortunately a common one. Apparently your doctor felt that the Vicodin was a reasonable short-term intervention to help with your severe arthritis. Then you had an additional problem, the spinal nerve injury, that was not amenable to the other treatments that were tried. So more Vicodin was prescribed. Again, your doctor probably thought of it as a short-term solution. Now your doctor no longer feels comfortable prescribing the Vicodin, so what do you do?
You actually have a number of reasonable treatment options. In all likelihood, a combination of these measures will be most effective in helping you manage your pain and have the most active, least disabling outcome of your illnesses.
First, as you are having a change in treatment regimen, you might want to talk with your doctor about getting a second medical opinion. Given the arthritis that started the pain problem, you might want to start with a Rheumatologist. If you are already seeing a Rheumatologist, you might request a referral to a Physiatrist, a rehabilitation medicine specialist, with a specialization in Pain Management. In either event, medical options are available to TREAT your arthritis, not just lessen the pain you experience. Other options are available for your spinal nerve pain as well.
In addition to treatment for the underlying medical conditions, a referral to a specialist in Behavioral Medicine may also be of help. A number of patterns of thinking, behavior and lifestyle can either increase or lessen both the experience of chronic pain as well as how limited you are by the pain. Evaluation of the role of these factors, and a treatment plan to address them, will likely help as well. As one example, we know that chronic pain, such as you experience, is also a source of chronic stress to the sufferer. Unfortunately, we also know that some of the biological consequences of chronic stress (e.g. release of certain stress hormones into the bloodstream) will also actually increase the physical experience of chronic pain. Thus, CHRONIC PAIN CAUSES CHRONIC STRESS, and CHRONIC STRESS WORSENS CHRONIC PAIN.
Numerous studies have shown that a variety of methods of Relaxation Training will reduce the experience and impact of chronic pain. These same methods are also effective in stress reduction as well. In fact, a consensus conference of the National Institutes of Health (NIH) in 1995 concluded that relaxation training was both an effective tool in the treatment of chronic pain and should be routinely included in treatment regimens.
You actually have a number of treatment options that, used in conjunction, may be quite helpful in the management of your medical conditions.
Sincerely yours,
Dr. Perry Belfer
What is the best treatment for Anorexia Nervosa?
Dear Dr. Belfer,
I have terrible secret to admit. It's not really been a secret to anyone but me for years. In fact, it really hasn't even been a secret to myself; I just haven't been able to admit it out loud. Now I can say it: "I'M ANOREXIC."
I've been dealing with this horrible disease for many years. I'm 35 years old and I've been starving myself for almost 20 years. When I was a teenager, my pediatrician and my parents put me in the hospital for a few days when I passed out at school. They dragged me to see a few therapists; psychologists, psychiatrists, social workers. We even saw a family therapist a few times together. Basically, I didn't want to be in treatment and they never really pushed it very far. I never saw anyone longer than a month or two.
Well now I know I have to do something. I don't know why it clicked; but I just don't want to live like this anymore. I don't feel like I have the energy to keep this up. I count every calorie, every morsel of food that passes through my lips. I NEVER, EVER let myself eat more than 1000 calories in a day, if that. And I exercise all the time.
So I spoke to my doctor; she recommended I see an expert for an opinion. I was so anxious, I wanted to see two. Now I have, and they both seem to say different things: one says I have to learn to change my thinking about my body shape, weight and food choices. The other says I have to better understand how I feel about myself and learn to handle painful feelings without dealing with those feelings though food. Which one is right? What should I do?
Sincerely,
Thoughts or Feelings
Dear Thoughts or Feelings,
Congratulations on acknowledging you have a serious problem! You have already taken the hardest step; after so many years of being trapped in the anorexia nervosa, you were very brave to face up to it.
That said, let's acknowledge that you have your work cut out for you. Whichever psychotherapist you chose, as an adult who has had this problem for many years, it will take time and persistence to beat. But again, you have definitely taken the hardest step already!
While it is hard to tell from your brief description, it sounds like the first psychotherapist might have been suggesting a Cognitive Therapy approach while the second one might have been recommending a Psychodynamic Therapy approach. For someone who has been dealing with anorexia nervosa for so many years, either is likely to be a perfectly valid approach to treatment. You need to work with someone who is highly experienced in treating individuals with anorexia nervosa and other eating disorders, and most importantly, someone with whom you feel comfortable. If you feel personally comfortable as well as confident of their expertise you will have a good foundation.
As you enter psychotherapeutic treatment, it will be important to maintain contact with your primary care physician who can help you address any medical problems that you currently have, or may develop, as a result of the chronic starvation and excessive exercise.
As you decide on which treatment to enter, it might be helpful if I provided a brief description of each:
COGNITIVE THERAPY will help you address the beliefs that you have with regard to yourself, your body, your weight as well as food and body shape and weight in general. In the course of treatment it is likely that feelings you have learned to cope with by focusing too much on food, weight, exercise and body shape will need to be addressed. You may be asked to engage in behavioral "experiments" to test your beliefs (for example, do you actually gain 10 pounds if you have a full turkey sandwich for lunch?);
PSYCHODYNAMIC THERAPY will likely focus more from the beginning on your feelings about yourself, people important to you, and your world in general. One form of such treatment, a Self-Psychological approach, involves a major focus on helping you to identify feelings, put your experience into words, and to learn to bear uncomfortable feelings without eating related behaviors.
In the end, if you are in the care of an experienced psychotherapist, both approaches will focus on helping you to deal with both the thoughts and feelings associated with your eating problems. Both treatments require a slow careful approach in the context of a highly supportive relationship.
A word about other treatments might be helpful as well: If you have other significant conditions in addition to the anorexia nervosa, medications can sometimes help. For conditions like obsessive compulsive disorder, or a full blown major depression (not simply feeling down or physically weak because you are starved), medication treatment is often quite helpful. If the eating disorder is significantly impacting your family and you are in close contact with them, it is possible family therapy, or at least some family meetings, might be useful. This treatment is often recommended for adolescents and less often recommended as a primary modality for adults.
It sounds like you have taken a careful approach to getting yourself into a good treatment. If you feel personally comfortable with the psychotherapist you choose as well as confident of their expertise you will get off to a good start. Best of luck and stick with it!
Sincerely yours,
Dr. Perry Belfer,
Did I Cause My Daughter's Eating Disorder?
Dear Dr. Belfer,
Our bright, accomplished, talented daughter recently returned from a summer in Europe between her freshman and sophomore years at one of our local colleges. When my wife and I picked her up at the airport, we were stunned. She was utterly emaciated. We immediately brought her to her doctor who told us that she had an eating disorder and needed to go into treatment. We were able to get her started pretty quickly in a day treatment program and she just graduated to only seeing her psychologist for individual therapy, her psychiatrist for medication, and her registered dietician for nutritional counseling, all as an outpatient.
No sooner does she start to look a little bit better than she comes home for dinner last Friday and tells us that my wife and I caused her eating disorder. What a nightmare! My wife is distraught; I'm deeply confused. She was always the perfect child. My wife and I love her deeply and she always looked up to us. I can't figure out what is going on here.
When we try to talk to our daughter about this, the conversation doesn't really go anywhere. We really have no idea what she is talking about.
We don't want to intrude on her treatment relationships, but we need some help here. Did we cause our daughter to develop an eating disorder? What does cause eating disorders? What should we do now?
Yours truly,
Confused and Fearful
Dear Confused and Fearful,
As your daughter is in the early stages of treatment, it is not surprising that she is searching to understand the roots of her eating disorder. During that search it would not be unusual for her to go up many paths and some blind alleys in her search for recovery and self-understanding. I certainly have no idea what specifically caused your daughter to develop an eating disorder. I can tell you though, that the causes are likely complex and composed of many factors.
It used to be common, both in health care circles and in the popular press, to blame the family for many emotional ills. Most health care professionals now subscribe to the biopsychosocial model of understanding mental health problems, including eating disorders. This implies that there are biological, psychological and social influences on the development and course of most conditions. Among the biological factors in eating disorders are the impact of excessive dieting, and genetic predispositions to substance abuse, depression, obsessive-compulsive and other anxiety conditions.
Among the psychological factors are certainly the impact of family relationships as well as peer relations, school experiences and available coping skills for managing stress. Social influences certainly include the influence of the media on our dieting culture and presence or absence of social supports.
By noting all of the above, I don't mean to imply that there may not be some rare, family situations that are so toxic that they virtually cause the eating disorder all on their own. But generally, there are multiple causes and multiple issues that need to be addressed in treatment.
In terms of your own situation, you might want to ask your daughter's psychologist or psychiatrist how you might best respond at this juncture. As your daughter currently feels the family was a major influence in her eating disorder, it may be that some family meetings with a licensed/certified mental health clinician experienced in working with families where there is an eating disorder would be helpful. Your daughter's psychologist or psychiatrist should be helpful in informing you whether such meetings are indicated now and with whom you might consult. If the recommendation is that family meetings are not currently indicated, perhaps you and your wife might benefit from the opportunity of speaking with such a family therapist yourselves to answer your questions and help you to develop a useful strategy for this stage in your daughter's recovery.
It does sound like you and your wife are embarking on a stressful part of your daughter's road to recovery. Good Luck!
Sincerely yours,
Dr. Perry Belfer