EATING DISORDERS
conference transcript
Bob M is the moderator.
BEGINNING
Bob M: Evening everyone. I'm Bob McMillan, the
conference moderator. I want to welcome everyone to the Concerned Counseling
website for our first Wednesday Night Online Conference of the new year. Our
topic tonight is EATING DISORDERS. Our guest is Dr. Harry Brandt. He is the
Director of the Center for Eating Disorders at St. Joseph's Medical Center in
Towson, Maryland. St. Joseph's is one of the few Eating Disorders specialty
centers in the country. Dr. Brandt is a psychiatrist. He's also a professor at
the University of Maryland Medical School. Prior to his present job at St.
Joseph's...he was, I believe, head of the Eating Disorders Unit at NIH (the
National Institute of Health. So he has quite a bit of knowledge on this
subject. Good Evening Dr. Brandt. Welcome to the Concerned Counseling website
and thank you for being our guest tonight. Besides my brief introduction, could
you please tell us a bit more about your expertise before we get into the
questions.
Dr. Brandt: Sure....I've been involved in the
treatment of persons with severe eating disorders since 1985. I have been both
a researcher and clinician on a full time basis. My current position involves
the direction of one of the largest eating disorder programs in our region. I
want to say good evening to everyone in the audience and thank you for inviting
me onto your site this evening, Bob.
Bob M: To start off, because there is such a
wide variety of people in the audience, what is an eating disorder and how do
you know if you have one?
Dr. Brandt: The eating disorders are a group of
psychiatric illnesses that have, as primary features, severe alterations in
eating behavior. The three most common disorders are anorexia nervosa, bulimia
nervosa, and binge eating disorder. Anorexia nervosa is an illness
characterized by starvation and marked weight loss. Persons suffering from this
illness feel grossly obese despite being extremely thin. They fear eating to
the point that they avoid caloric intake at all costs. Further, they often have
a range of physical problems as a result of their illness and behaviors.
Bulimia nervosa is characterized by episodes of significant binge eating,
perhaps thousands of calories in an episode. Then, to counteract the binge
episodes, persons with this illness will use various behaviors in an attempt to
reverse the caloric intake. Self induced vomiting is common, but many people
will use laxatives or fluid pills or compulsive exercise or fasting. Anorexic
patients are at low weight., while bulimia nervosa can exist at any weight.
Complicating the diagnosis is the fact that many anorexic patients will also
pursue bulimic behaviors (approx. 50%). And many persons with bulimia nervosa
will have wide fluctuations in weight as well. Both illness are highly
dangerous with significant morbidity and mortality. The third major eating
disorder is the most recently defined....binge eating disorder. This is similar
to bulimia nervosa, but without the compensatory purging behavior. Many of
these individuals are at an above normal weight because of their eating
pattern. In addition to the basics that I have outlined thus far...there are
many associated features of each illness.
Bob M: Why does someone develop an eating
disorder and is there anything new that's been uncovered in recent research as
to the "why" question?
Dr. Brandt: There are many factors that are
involved and I will highlight three major areas. The first is our culture. We
are obsessed with thinness as a culture to the point where there is a
tremendous emphasis on weight, shape, and appearance. This has increased
through the decades, to the point now where just about everybody is worried
about their weight. This even includes people who are at a perfectly normal or
appropriate weight. As people attempt to manipulate their weight with dieting,
they are at greater risk of developing one of these illnesses. The second
factor that must be considered is a person's life history and underlying
psychological issues from development. We see many common psychological themes
in our patients with severe eating disorders. The final area I would highlight
from the perspective of etiology or "why" is the biological arena.
There has been an explosion in research about the control of hunger and
fullness and weight regulation, and there are many important new developments
in our understanding of these highly complex problems. Perhaps we can explore
some of these in more detail this evening.
Bob M: What are the treatments for an eating
disorder? And is there such a thing as a "cure" for an eating
disorder? If not, is there a possibility of a cure in the future?
Dr. Brandt: The treatment of eating disorders
begins with a diagnostic evaluation, and is guided by the nature and degree of
symptoms and difficulties. A first step is to rule out any immediate medical
danger in persons dealing with any of the eating disorders. Then, one needs to
assess whether the individual can be treated on an outpatient basis, or whether
a more structured, hospital-based setting is necessary. Often, persons with
less severe eating disorders can be treated on an outpatient basis with some
combination of psychotherapy, nutritional counseling, perhaps medication if
indicated. If a person is unable to block the dangerous behaviors of the
disorder on an outpatient basis, then we encourage the patient to consider
inpatient or day treatment or intensive outpatient programs.
Bob M: Is there a cure though for an eating
disorder, or one coming in the near future, or is it something that an
individual deals with forever?
Dr. Brandt: Some patients do extremely well
with appropriate treatment and may be considered "recovered."
However, many will struggle with these illnesses for long periods of time. It
is our hope that the treatment of these illnesses will continue to improve as
we learn more about the causes and new therapeutic strategies emerge. I have
seen tremendous strides in the past decade!! Also, there are a number of new
pharmacological strategies. And psychotherapies are becoming increasingly
refined.
Bob M: Here are some audience questions Dr.
Brandt...
Hannah: Dr., I was wondering if my mitral valve
prolapse could be the result of my anorexia and occasional bulimic behaviors?
It started about 3 years ago.
Dr. Brandt: Mitral valve prolapse is a common
problem. It is possible that it is unrelated to your eating disorder.....but it
is also possible that your eating disorder is complicating the problem. I
suggest you see your physician regularly.
Snowgirl: What do you do in the face of a
relapse?
Dr. Brandt: Do not get discouraged. Eating
disorders can be nasty illnesses, but if you keep trying you can overcome it.
Also, reevaluate the treatment you are receiving if you are not progressing.
SS: What have you seen as the most successful
course of therapy?
Dr. Brandt: I think the best treatments are
multi-modality. Many persons do well with combinations of individual
psychotherapy, nutritional counseling, sometimes family therapy and, if
indicated, medication. Also, if things are not improving, consider inpatient or
day hospital treatment.
Ragbear: I have been in recovery from
bulimarexia since 1985--- when I had my last purge after 8 years (daily) active
bulimia. I still battle low self-esteem (poor body image)... what can I do?????
Dr. Brandt: You should be proud to have
conquered a difficult illness like bulimia. Now your attention needs to focus
on what is behind your low self-image. Perhaps the self-image problem was the
underpinning of your bulimia. I am sure that if you put your mind to it, you
can figure it out.
Bob M: Before we get to the next question....if
you haven't subscribed to our free email newsletter which contains our site
happenings and the latest news in the mental health area...please send me your
name, email address to: newsletter@concernedcounseling.com. Also, I am getting
a lot of questions about our new online counseling groups which start in
February. We are having eating disorder groups. There will be a maximum of 5
people to one counselor and we can set up as many groups as warranted.
CountryMouse: My question for Dr. Brandt is,
what is wrong with NOT getting help for a "borderline" ed? I am a 36
year old woman, 5'3" and weigh 95 lbs. I have no real health problems due
to my weight except for being cold all the time and dry skin. I definitely do
not want to gain any weight, and think I can control my ed by staying at this
weight. Also, I'm not really ready to admit that I have a problem, so I would
need to face up to this before seeking treatment, right? I just don't want to
gain weight.
Dr. Brandt: Obviously you DO recognize that you
have a problem, or you would not be here. The bottom line is that a hallmark of
anorexia is the massive denial that accompanies the illness. I have known many
persons with so-called "borderline" illness who went on to have
significant problems that could have been avoided if they had gotten the help
they needed earlier. I suggest you face the harsh realities of your situation
and get the help you need.
Bob M: Dr. Brandt, you mentioned earlier that
there were some exciting new drug and psychological therapy treatments coming
for treating eating disorders. Could you please elaborate?
Dr. Brandt: Certainly. The first point I would
make is that the newer medications used to treat depression....such as Prozac,
Zoloft, Paxil, and others are highly effective in the treatment of some
patients with severe eating disorders. We are part of a multicenter study
looking at a major antidepressant in decreasing relapse rates in bulimia
nervosa and the results are quite promising. Further, the newer drugs can be
used with greater ease in persons at low weight. From a psychotherapy
perspective, there has been tremendous progress in dynamic psychotherapy,
cognitive behavioral therapy, and group therapy techniques in the treatment of
eating disorders. Additionally, we are using videotaping in expressive arts
therapies to work on body image distortion.
Bob M: What are the names of these new drugs?
Dr. Brandt: The newest drugs that we are trying
are mirtrazepine (Remeron) and the selective serotonin reuptake inhibitors, as
well as the mood stabilizing agents (depakote, gabapentin, lamotrigine).
Pharmacologic treatment of the eating disorders is complicated by the
comorbidity that we see with anxiety, mood disorders, personality disorders,
and other psychiatric illnesses.
Angela98: What about people who have symptoms
of both anorexia and bulimia?
Dr. Brandt: Many individuals do have both
symptoms. This a particularly serious form of eating disorder that requires
intensive treatment approaches. One needs to pay attention to the dangers of
starvation coupled with dangers of purging.
LD: I think that I have relapsed into my
anorexia, because I don't want to eat. I am 96 lbs. and 5'3" and I am
afraid of becoming even worse, but I am not sure I want to get better. How do
deal with this? It is ruining my life, but it was so hard to deal with the
first time.
Dr. Brandt: I think you have made an important
first step. People with eating disorders are not happy DESPITE being at a low
weight. The bottom line is that life can be a whole lot better if you take
responsibility and face your illness. I have seen many recover through the
years and it is very rewarding.
Bob M: There are some parents in the audience
tonight who think their children may have an eating disorder. What is your
advice to them, or a friend of a potential e.d. individual, in trying to
approach them? The do's and don'ts.
Dr. Brandt: I think it is perfectly reasonable
to approach a family member or friend if there is suspicion of an eating
disorder. I think it is important to be direct, open, and honest with the
person, but not judgmental. Parents often have to play a major role in helping
their child get the treatment that is essential. It is probably better to focus
on the way the individual is feeling as opposed to focusing on food, calories,
weight, etc. I think it is tragic when friends and family stand by and avoid
getting involved if someone they care about has a dangerous eating disorder. On
the other hand, I have also seen situations where parents and/or friends get
over-involved and forget that the patient has the primary responsibility.
LostDancer: Dr. Brandt, if you are pregnant and
have anorexia and/or bulimia, what could be some of the possible ramifications
if the person would continue the behaviors of anorexia and/or bulimia through
the pregnancy or at least for awhile into the pregnancy?
Dr. Brandt: We have had several patients in
this situation. It is essential that a person who is pregnant and dealing with
an eating disorder get rapid and comprehensive treatment. The situation can be
dangerous to both the patient and the baby and needs very careful monitoring.
Nutrition is a critical element in all eating disorders, but particularly in
this complex situation.
UgliestFattest: I have eaten 2 pieces of toast
today and feel like I am grotesque for eating at all. Why can I not see what
others see? I know what the scale says, yet I see something totally different.
My scale says less than 100, yet I see a 1000 pound person when I look in the
mirror.
Dr. Brandt: You are describing in detail the
global distortion in body image that we see in persons with severe eating
disorders. You need to face the reality that your mind is playing a nasty trick
on you. You must not respond to these inappropriate messages from your mind,
and instead, you must force yourself to take in adequate nutrition that is
necessary to sustain you. Good luck.
Susan: Do you feel that antidepressants are
helpful when treating eating disorders?
Dr. Brandt: Yes, the antidepressants are among
the most important medications in the treatment of eating disorders. They have
a primary impact in reducing impulses to binge and purge. And further, they are
important because of the high rates of depression that we see in both anorexia
nervosa and bulimia nervosa. Many of our patients are on these medications, and
they benefit significantly.
rayt1: I am a 45 yr. old male anorexic with
onset at 30. Have you run into any other such cases ? I am 5'10", current
weight of 100 and lowest at 68 lbs.
Dr. Brandt: Yes! We are seeing more and more
men developing these illnesses. As our culture changes, some of the stereotypes
of who develops an eating disorder have broken down. In the past, I think many
men who had this illness were afraid to come forward because the illnesses were
thought of as women's diseases. The bottom line is that eating disorders can
affect just about anybody.
Bob M: Here's a great question from Lorin, Dr.
Brandt:
Lorin: Dr. Brandt, Managed care companies are
now getting tough with much needed medical hospitalizations , when it is
clearly needed when a patient is at 70 lbs. Where can someone turn for help
when insurance won't pay and people can not afford the inpatient treatment?
Dr. Brandt: This is a problem that we are
confronted with on a daily basis. In Maryland, those without insurance can
apply for Medical Assistance (Medicaid) and get help through this program.
Also, there have been some research-based programs, where a person could get
free treatment in exchange for participation in research studies.
Unfortunately, there are not many resources. We work hard to encourage managed
care companies to pay for treatment that is essential.
Bob M: Does the St. Joseph's Eating Disorder
Center have a research program with free treatment? If so, how do people
register or find out more about it?
Dr. Brandt: Our research efforts are all
outpatient at the current time. People can contact us at 410-427-2100 or log on
to our web page at http://www.eating-disorders.com
Tammi: Is it possible to not practice bulimia
for years, but not really be in recovery, meaning the problem was never really
dealt with?
Dr. Brandt: Recovery is not simply not binging
or purging, although this is an important first step. Recovery also entails
more healthy attitudes about food, weight, and appearance.
Rosemary: My 19 yr. old college student
overachiever daughter had a major disappointment, fell into depression, quit
eating for a time and now is having trouble eating. She is not receptive to
getting help. What can be done?
Dr. Brandt: I think it depends on her degree of
illness. If she is significantly underweight, I think you need to become quite
active in encouraging her to get the help she needs. If she says she is
"ok", tell her that you would feel better if that was confirmed by a
physician. If she is very sick, and unwilling to seek help, you might be forced
to use the legal system to make sure she gets the help she needs. But this is
only possible if physicians, or the courts, see her as an imminent danger to
herself. I suggest you try to be direct, honest, and hopefully, persuasive.
Maigen: How does a physician
"confirm" an eating disorder?
Dr. Brandt: The diagnosis of an eating disorder
is made based on a comprehensive review of signs and symptoms, and a careful
history taken by a skilled clinician. One needs to carefully review and assess
a person's patterns of eating, and take a careful weight history with an eye
toward family genetics.
Bipole: Well, I am bipolar II, and multiple
personality disorder - dysfunctional background (incest), been in therapy. I've
tried and tried to lose weight - sometimes I lose some, but I can't keep it
off. When I fail on the diet, I get very suicidal. I'm almost afraid to try
again -can't stand another failure. I am diabetic (2) with cholesterol through
the roof. What can a person in this situation do to be successful once and for
all? Thank you..
Dr. Brandt: A review of personality
characteristics, and many other factors is needed. Then, a person should
undergo a complete physical and laboratory evaluation as well. We do not
believe that dieting is useful to anyone. Our focus is on health- normal food
intake- that is guided by a person's hunger and fullness cues. We also believe
the focus should be on healthy nutrition and not on weight. Restrictive dieting
tends to cause feelings of deprivation...and in the long range, only creates
greater difficulties. Further, yo-yo dieting with wide fluctuations in weight
causes significant disturbances in energy metabolism and is counter-productive.
Bob M: Bipole, you might also need to be under
a medically supervised program. You should contact your dr. about a referral.
Vandy: Are there any 1-800 numbers for people
with eating disorders to call and talk to someone? I know they have them for
suicide, depression, etc., but all the eating disorders hotlines I've found
have to be paid for. I don't know about anyone else, but this makes me feel
less important and I would really like something like that to be available.
Dr. Brandt: Yes, there are a number of
organizations and 1-800 numbers. I don't have them in front of me but feel free
to call us at 410-427-2100 and we can guide you.
AngelTiffo: I wanted to know what your opinion
is on Peggy Claude Pierre's treatment?
Bob M: While you are answering that question,
maybe you could tell us briefly what the thesis of that book and her method of
treatment is, Dr. Brandt?
Dr. Brandt: I believe that Peggy Claude
Pierre's treatment is unproven. There has been tremendous interest in her
treatment since she appeared on 60 minutes a couple of years ago. The thesis of
her treatment as I understand it, is that, she and her staff tends to take over
many of the functions for patients with severe anorexia. She was noted to hold
and cradle patients during her appearance on TV. She seems to focus on
"reparenting" of persons with severe eating disorders. What is
notable is that she has made fantastic claims....but has not allowed her claims
to undergo scientific scrutiny by the experts in the field. I have concerns
about the regressive nature of the treatment, and concerns that many patients
will have significant difficulty after the treatment. Further, I was quite
concerned that Princess Diana had turned to her for advice about her eating
disorder, and that she went public with that information after Diana's death.
That seemed to me to be ill-advised, inappropriate, if not unethical. Overall,
there have been many claims that have not been substantiated. Our view is that
the patient with a severe eating disorder needs to be an active, collaborative
participant in the treatment process. We try as best we can NOT to take over
for the patient, but rather, to engage the patient in a collaboration.
Bob M: Regarding that: here's a comment from an
audience member...
Dickie: Makes it hard to trust any doctor.
Dr. Brandt: Dickie, I think many physicians are
highly ethical and trustworthy!!!! Of course, I may be biased.
Trina: Dr. Brandt, in regards to the
"regressive nature" of Peggy Claude Pierre's treatment - wouldn't it
be effective psychoanalytically to regress?
Dr. Brandt: I believe many people who suffer
ED's do want doctors to take responsibility for their treatment. It's quite
hard to collaborate in treatment when one is clueless and helpless? Yes, but
regression in psychoanalysis is different from what Ms. Claude Pierre is doing.
Psychoanalysts encourage patients to speak their thoughts freely, and patients
might regress. But there is not the active encouragement to regress in the way
that Ms. Claude Pierre seems to be encouraging. The psychoanalyst maintains
neutrality. I agree....many patients do want the physician to take over, but
that does not mean the physician should do so. The reality is that the
physician must encourage autonomy.
LJbubbles: I want to know what the symptoms are
of a relapse and also, if you have an anorexic in your family is it possible to
'pick up on' some of their symptoms.
Dr. Brandt: Relapse symptoms include
restrictive eating, trips to the bathroom during and after meals, social
isolation and withdrawal, depression, obsessive focus on weight and appearance,
etc. Regarding "picking up symptoms" from family members, if you are
healthy, the answer is "no".
Pele: I just spent 2 weeks at a seminar in
London. Things (as far as the ED were concerned) were fine. Now that I have
returned home, I have fallen into the same bulimic behaviors and thought
patterns. Why was I okay there, but here I can't keep that up?
Dr. Brandt: There are perhaps many reasons for
your difficulties. Perhaps there are stressors at home you were able to escape
while in London.
Livia: I feel that eating disorders has
something to do with control. Is there any pattern among the ones that have
binge disorder?
Dr. Brandt: I agree that eating disorders often
do center on feelings of control or lack of control. We see themes in our
patients of difficulties in this arena.
Lonely: Can you ever fully recover from an
eating disorder--with out relapse?
Dr. Brandt: Yes, I have seen many people with
rather severe eating disorders manage to build the necessary psychological
structure and supports in the outside world to fully recover from an eating
disorder.
MikeK: What one book would recommend that a
parent of a child with an ED read?
Dr. Brandt: I would recommend reading "The
Golden Cage" by Hilda Bruch.
Maigen: If you are restricting your calories,
such as avoiding all foods with fat, and not going on "typical"
binges, but you are purging, does this make you both anorexic and bulimic, or
just bulimic? What is your opinion?
Dr. Brandt: The "label" or
"diagnosis" is not what is important here....what is important is
that the pattern of eating behavior that you describe is of serious concern. I
suggest you get help from a professional.
Bob M: It's getting late, here's the last
question Dr. Brandt...and let me say at this point, I really appreciate you
coming onto our site this evening. I know you can't see it, but the audience
has sent me many comments on how much they have learned from this discussion.
Also, FYI, because I'm getting a lot of questions on our online counseling
groups that start in February. Here's the final question Dr. Brandt:
Jen: How do you know when it is time for
inpatient therapy?
Bob M: And by the way Dr., how long does it
take for a person to "overcome" or deal successfully with an eating
disorder?
Dr. Brandt: There are a number of factors in
evaluating someone for inpatient: 1. Failure of access to a well designed
outpatient program; 2. Severe metabolic (physical) abnormalities; 3. Rapidly
progressing weight loss which is not reversing on an outpatient basis. Ongoing
progressive binging and purging, with danger of electrolye (elements in blood)
disturbance; 4. suicidal risk or progressive depression; and, 5. Limited family
support or structure. These are some of the factors we use in making this
complex decision. Before I sign off, I'd like to thank all who attended and
asked such fine questions. I've really enjoyed being part of this interesting
format. Feel free to call us at 410-427-2100 or visit our website at
http://www.eating-disorders.com Thanks!!!!
Bob M:Thank you again Dr. Brandt for coming and
for staying late like this. We appreciate it. And I want to thank everybody in
the audience for coming tonight and participating. I hope you got something out
of it. We hold these topical mental health chat conferences every Wed. night at
the same time...so please come again. Thank you for coming tonight Dr. Brandt.
Good night everyone.
Dr. Brandt: My pleasure Bob. I hope to be
invited back soon.
Bob M: Good Night everyone.
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