Transcript from online Conference with Holly Hoff on "Identifying and Preventing Eating Disorders" and Dr. Barton Blinder on "Understanding and Working Through Your Eating Disorder"

Bob M: Good evening everyone. I'm Bob McMillan, the moderator. I notice some new people here tonight...and I want to welcome everyone. As you know, this is Eating Disorders Awareness Week. We are doing many conferences on our site this week and you can find the schedule link at the entrance to the chatrooms when you log on. Our first guest tonight is Holly Hoff. Holly is the program coordinator for Eating Disorders Awareness and Prevention Inc. It's a national non-profit group based in Seattle, Washington. EDAP is dedicated to increasing awareness of eating disorders in general and also the prevention of them. Good evening Holly and welcome to the Concerned Counseling website. I'd like to cover two specific topics that we get questions on all the time. The first one is prevention of an eating disorder. Is that possible?

Holly Hoff: I'm glad to be here tonight. Prevention is a main part of our business. Prevention and early detection are keys to working towards eliminating eating disorders altogether. We have programs at the elementary, high school and college levels that are aimed at awareness just for that reason.

Bob M: So how does one go about specifically preventing having an eating disorder.

Holly Hoff: We feel it's important for people to have correct information about some of the unlying causes of eating disorders. It's important to consider social, family, emotional, and physical elements. Each can lead to an eating disorder.

Bob M: What is the leading cause to developing an eating disorder?

Holly Hoff: We don't have a definite answer on that. Research is being done right now. It starts for some as a result of physical, sexual, or emotional abuse. For others, it's pressure to be thin. It could be a result of feelings of inadequacy, depression, and loneliness. Troubled family and personal relationships can also play into it. One cause we work to fight is the social ideal of a perfect body, unrealistic images of beauty.

Bob M: I see more people coming in. We are talking with Holly Hoff, program coordinator for Eating Disorders Awareness and Prevention, Inc. When do most people start experiencing an eating disorder? At what age? (eating disorder facts)

Holly Hoff: There are two typical ages of onset. Adolescence and then 18-20 years old. But they can certainly happen at anytime in a person's life. The earlier periods tend to be times of major change in a person's life. Change can often cause stress and eating disorders are often more than just about food. They can be reactions to difficult times in a person's life. These are also times when a person's body changes. That's a scary thing for some teens and unfortunately we're not often taught to expect or appreciate those changes and growth.

Bob M: I know we have some parents here tonight and friends of people who may be experiencing or starting to experience an eating disorder. What are they supposed to do to help?

Holly Hoff: It's important for them to learn about eating disorders. One way to do that is by calling our office at 206-382-3587 and we will send them eating disorders information. It is also important for these people to find support for themselves because it can be a difficult experience emotionally...dealing with someone who has an eating disorder. Express concerns in a calm and caring way. Encourage the person struggling to take responsibility for their actions and seek help for eating disorders. You can also be a good role model about food, weight, and body image issues.

Bob M: Now what do you mean by, be a good role model?

Holly Hoff: Avoid speaking negatively about their own bodies. Eat a variety of foods and eat in moderation and exercise for fun rather than strictly out of a sense of obligation. Avoid concentrating too much on other people's physical appearance, including size and shape.

Bob M: One other thing I want to add to that is, try and be non-judgmental and supportive. From talking with the many visitors on our site with eating disorders, that is something they really struggle with. They complain that their friends and relatives constantly criticize them for their eating disorder, rather than being supportive and helping them find the help they need. I know one of the visitors here refers to her boyfriend or husband as the "food cop"...always monitoring how much she is or isn't eating. So Holly, how does one approach someone with a suspected eating disorder with their concerns?

Holly Hoff: Honesty is important. I agree, being the "food cop" doesn't work. It forces many people into secretive eating. That is really counterproductive. Then they start lying about their situation. Express concerns and caring. Use statements like "I've noticed", "I see", "I feel". But remember, the person struggling with an eating disorder must take responsibility in order to change their behaviors.

Bob M: Here are some comments from the audience and then I'll post a few audience questions for Holly to answer.

Scout: One way of helping prevent eating disorders, in the thin sense, is do away with the thin models and use people with normal bodies.

Jo: Bob -- the person struggling must take responsibility -- very true -- but you aren't speaking to the fact that these problems were given to us as we were growing up. When do parents recognize they are doing these things to their children?

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Maigen: My mom doesn't ask me much about my eating disorder, but when she does, she is bribing me to stop. One time she offered me a car if I'd stop. How do I explain that I would stop for her and for myself if I could. She certainly has no clue and there is no support or help around where I live. Are there any certain books I could ask her to read? Anything?

Holly Hoff: Jo, that's why we are trying to educate people of all ages, so that parents can help their children. Young people and adults need to realize their comments and behaviors affect others. This is what I mean by "parents modeling healthy attitudes and behaviors." Maigen, I am having my assistant grab a reading list and I'll get to your question in a few minutes. One thing that might help is a newsletter we put out. You can get that by calling our office at 206-382-3587. It costs $15 for student memberships and $25 for the general public and $35 for professionals. Here are some of the books:

• Surviving an Eating Disorder-Strategies for Family and Friends-by Judith Brisman
• A Parent's Guide to Eating Disorders: Prevention and Treatment of Anorexia and Bulimia by Brette Valette.
• And one of your audience members suggested: The Secret Language of Eating Disorders.

If anyone wants a longer list, we have a 3 page one we can send. Just call our office.

Champios: Wasted- by Marya Hornbacher is another one which gives a fairly accurate description of ed's.

Scout: Also, "The Best Little girl In the World," fictional work on anorexia.

Spiffs: I was wondering if there were any online screening tests to help determine what eating disorder you or someone you know has?(eating attitudes test)

Holly Hoff: Most of the online tests are listed "for your enjoyment only." It really takes a professional to make that assessment. Here's an 800- number for the National Screening Project and they are doing screenings this week all across the nation. 800-969-6642. And people can get more info on education at our website: http://members.aol.com/edapinc. The other thing we also tell people is that if you suspect that you, or a friend or relative has an eating disorder, then that's good enough reason to talk to a professional psychologist or psychiatrist about your concerns. Early detection is important for eating disorder recovery.

PegCoke: What can people without money do to help a friend with an eating disorder? I can't afford to make long distance calls, subscribe to newsletters, or buy books.

Holly Hoff: That's very difficult PegCoke. Because really to get the professional treatment it takes either money or insurance, in most instances. You might want to try and get on medicaid through your local social services' office. We offer free information for anyone who needs it.

Rachy: What if your ED didn't just develop? I mean what if you knew what you were doing and MADE it come. I know that I played with a lot of ideas before anything stuck in.. I don't even know if I have an ED or if it just a phase.

Holly Hoff: The danger in eating disorders is that people may experiment with the behaviors. Unfortunately, they can quickly become habit and spiral out of control. I would encourage you to see a professional about your situation.

Bob M: We are talking with Holly Hoff, of Eating Disorders Awareness and Prevention. Dr. Barton Blinder will be here in about 15 minutes and we'll be discussing the latest treatments and research on the subject. Here's a few more audience comments...

Jane: Holly, I admire you for what you are doing. Somewhere and somehow it has to reach more people though because if the chain of dysfunction isn't broken it carries on and people don't seem to know how to be anything other than what they were brought up as.

Journey: I struggle with body image a lot! Any helpful ideas on how to work on seeing my body as others see me?

Bob M: Onto more questions:

Jrains: I understand that even in the medical profession, there is an ignorance about the severity and even existence of EDs. Where do you look for good professional help?

Holly Hoff: There are organizations jrains that can recommend eating disorder professionals, people with expertise in that area. The National Eating Disorders Organization-NEDO-is one. 918-481-4044. It is important to continue seeking a qualified professional, if one isn't a good fit, move onto another.

Bob M: And I want to add here, that a professional is someone who is a licensed Ph.D. psychologist or M.D. psychiatrist who specializes in eating disorders...not just knows about them. It is up to you to interview the doctor. And you have every right to do that. That's your money (whether cash or insurance) and health on the line.

Holly Hoff: I agree wholeheartedly Bob. There's another group called ANAD.

Bob M: And while I'm thinking about it...and the money angle...there are university and college research centers around the country. If money is a concern and you are serious about treatment, you might want to call around and see if you can get free, or low cost treatment, by participating in the program. By the way, Holly's group does not have an 800 number. I was getting some questions about that.

Holly Hoff: I'm not sure what you mean by the "optimal dose" but would suggest a trial of Adderall or Desoxyn.

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Champios: So what is your best suggestion for those of us with eating disorders that are working on getting better on our own?

Holly Hoff: That's a very tough question. You might try support groups in your area. And as Bob mentioned, I would check on signing up for medicare if you can't afford treatment. And either NEDO or ANAD can give you the phone numbers for support groups in your area.

Bob M: Here's an audience suggestion on that champios...

Maigen: After my parents got divorced, my high school paid for my therapy. If you have a school psychologist, it is possible to get counseling therapy. You should check with your school counselor.

Jo: Bob and Holly -- this is all very well and true -- but a lot of young people don't get the help because 1st of all the parents do not let themselves recognize there is a problem and then many still have an old fashioned view that psychologists and psychoterhapy are something to be ashamed of. So they won't seek help.

Liz B: Also a lot of kids and teens do not tell their parents.

Bob M: That's a good point Liz. Holly, how does a child, or teen, confide in their parents without the fear of something "bad" happening to them?

Holly Hoff: It's definitely important to talk to an adult about what you are going through. For teenagers, getting help for an eating disorder will probably involve their parents finding out at some point. Without telling, eating disorders can be life-threatening. They need immediate attention.

Bob M: And I have to believe that most parents care about and love their children. You have to be realistic and understand that your parents will be concerned, but hopefully, after maybe the shock, or surprise, or traumatic worry wears off, they will be supportive and help you get the help you need. Here's another question Holly:

Katerinalisa: What about for those who have insurance but have used it up? What can we do? How do we get treatment after starting, but running out of insurance or money?

Holly Hoff: Kat, that is very difficult. I know that some insurance policies do run out...and if you sign up for another one, there is at least a one year wait for a preexisting condition, if they will cover it at all. Again, try what Bob said. If you qualify, try for medicare or a treatment research program.

Bob M: Here are a few audience comments:

UgliestFattest: I make $333 a month and have no insurance and cannot get medicaid because I am not under 21 or not pregnant plus I am not a US citizen. I am getting therapy through the local MHMR (Mental Health Mental Retardation) center. I have a wonderful therapist and I don't pay a penny because they go by my income and I am supporting myself and putting myself through college.

Maigen: That is true Holly. My mom found out, even though I thought that I was hiding it well. I am glad that she knows. Someone should know, so you don't feel so alone.

cjan: I am in an eating disorder support group and see a therapist. One book I found to have some good self-help advice was "Overcoming Binge Eating" by Dr. Christopher Fairburn.

Bob M: This is the last question for Holly. Dr. Barton Blinder will be coming in about 5 minutes. He's a psychiatrist and eating disorder treatment and research specialist. If you have any further questions for Holly, now's the time to ask.

cjan: I find that a lot of my binges and general overeating is stress related. I am trying to find healthy alternatives to binging. Any suggestions?

Holly Hoff: Find an activity you enjoy. Something to get you away from the food. Walking, reading, talking to friends. Anything that can keep you and your mind doing other things. It's good to have someone to talk too in that situation...for support.

Bob M: Thank you very much Holly. I think we learned a lot tonight. And the one point I want to make is...you can't keep your eating disorder a secret if you need help...and secondly, not dealing with it, doesn't make it go away.

Holly Hoff: Thank you Bob and everyone for having me here tonight. I hope that some of the tips and resources I have given will be a help.

Bob M: Our next guest is Dr. Barton Blinder. Dr. Blinder is the Director of the Eating Disorders Program and Research Studies at the University of California. He is an M.D. Psychiatrist and has many years of practice in the field as well as publications to his credit. Good evening Dr. Blinder and welcome to the Concerned Counseling website. Could you start by filling us in a bit more about your expertise in dealing with eating disorders?

Dr. Blinder: I began clinical and research experience with eating disorders with residency training over 25 years ago. At the University of Pennsylvania Dept. of Psychiatry, we began systematic studies of the symptoms, diagnosis, prognosis, and experimental treatment approaches for anorexia nervosa. This included the first behavioral approach to eating disorders and the first careful evaluation of the rituals and obsessions connected with eating.

Bob M: What kind of research have you, and are you, involved in?

Dr. Blinder: In the past several years, we have completed the first successful trials of an SSRI, Prozac for the acute treatment, and more recently relapse prevention for Bulimia Nervosa. We also have accomplished the first brain imaging studies, PET scans of Bulimia Nervosa, differentiating it from depression and showing brain pattern similarities to obsessive-compulsive disorder (hyperactivity in caudate nucleus of the mid brain) which may be involved in food seeking and ritual driven food related behaviors.

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Bob M: From your research and knowledge, can you tell us, have scientists been able to come up with "what causes an eating disorder?"

Dr. Blinder: The causes are of course multi-determined and complex. There appears to be a moderate genetic component, certain developmental attachment disturbances which may effect the regulation of many self systems (mood, activity, aggression, and eating). Neuro transmitter abnormalities in the hypothalamus (effecting meal size, satiety, and carbohydrate craving, abnormalities in the caudate nucleus affecting food seeking and ritual behaviors). And finally abnormalities in the gastrointestinal--brain stem circuit which may perpetuate vomiting behaviors in bulimia nervosa. Certainly psychosocial and developmental phase (adolescents) may play a promoting role.

Bob M: I want to divide the treatment research information into two categories. First, we are interested in knowing what are the latest medications available, or about to be available for eating disorders treatment, and how effective are they?

Dr. Blinder: The new generation of medications will be very specific in targeting the neuro chemicals (peptides) that initiate, promote, and regulate feeding in the brain. These include Leptin (hormone with origins in the body fat signaling the brain), Neuropeptide Y (strong stimulator of feeding), Orexin (neuro hormone in hypothalamus which strongly stimulates feeding), and Galinin (neuropeptide which stimulates the eating of fat). The new medications will block/regulate/modulate these very specific neurohormones to help in regulation of feeding. Along with behavioral approaches and nutritional counseling we may also have laboratory tests to determine the excess or deficiency of these neuro hormones and thus have a rational approach to treatment for the first time.

Bob M: And what about the psychotherapy end of the treatment? Has their been any advances made in that?

Dr. Blinder: Guidelines of the American Psychiatric Association stress the cornerstones of nutritional rehabilitation, eating disorder psychotherapy, and medication along with medical and dental follow-up. Cognitive behavioral psychotherapies have the strongest evidence of positive outcome; however, family and psychodynamic therapy is extremely important in younger patients and where there has been developmental complex psychopathology. Where there is chronicity, co-morbitity, and severe developmental complexity, a treatment team should be assembled and the therapeutic approach conducted at the highest level. This may include brief medical/psychiatric hospitalization, an initial period of residential treatment, and a carefully formulated outpatient treatment plan. Limited treatment approaches are definitely not the practice standard in these disorders.

Bob M: We are talking with Dr. Barton Blinder, psychiatrist, Director of the Eating Disorder Program and Research Studies at the University of California. I'm going to ask this question and then we'll open the floor to audience questions. What is the most effective treatment for Anorexia and Bulimia available today? And can one who has an eating disorder, ever expect a full recovery?

Dr. Blinder: About 2/3 of patients with eating disorders recover in 5 years. However, 10 year follow-up studies have shown persistence of symptoms and rituals, continued medical difficulties, and a rate of suicide 10 times higher than expected for age group. The most effective treatments are those reviewed in the APA Practice Guidelines and those that have valid outcome studies. We must continue to emphasize early detection, proper diagnosis, and the best interventions at each phase of treatment. Most treatment failures are related to difficulties in the intensity of each treatment phase.

Bob M: Here are some audience questions, Dr...

UgliestFattest: Dr. Blinder does it become harder to recover from an eating disorder the longer you have it? I am 24 and have had an eating disorder ever since I could remember, which is about age 9. What is the liklihood of me ever fully recovering?

Dr. Blinder: Chronicity (persistance) of the disorder is a factor that definitely leads to treatment resistance. In most instances there are coexisting psychiatric difficulties (depression, OCD, anxiety) and autobiographical complex factors that need careful psychotherapeutic attention. Often a period of residential treatment as the first phase of a carefully sustained treatment plan can be a turning point. Hope should continue and support and understanding of family and significant others is critical.

Bob M: Earlier you quoted some statistics that 2/3 recover in 5 years, but that studies indicate the symptoms really don't ever completely disappear. With that in mind, here's the next audience question:

Champios: So the prognosis is relapse?

Dr. Blinder: No. About 1/3 continue some level of symptoms. Relapse occurs in a small percentage, but the more likely course is either reasonable recovery or chronic persistence (subtle/low level/openly apparent).

Pumpkin: Dr.Blinder, can you tell us exactly how an eating disorder is diagnosed? I know that a lot of people think that sufferers of anorexia have to be extremely underweight to be diagnosed with that disorder.

Dr. Blinder: We have been more liberal with our diagnosis recently (APA DSM IV). Anyone with 15% weight loss or maintaining level below minimum for height and age is current criteria. Obsessive ideas and rituals (including body image disturbance) and unusual food related behaviors are a part of the picture. The important thing is that the behavior is daily, unrelenting, and leads to nutritional decline and psychosocial handicap.

KJ: Information that I am receiving are things I already know. I know it's dangerous. I want to change, but can't. Even if I had the miracle cure in a bottle right in front of me, I wouldn't dare take it in fear of becoming fat. How do I go about getting rid of this?

Dr. Blinder: The fear of fat is a "code word" for a complex set of obsessions about the body and bodily control. This includes dissatisfaction with self, unusual body experiences, and pervasive sense of ineffectiveness in self care. Therefore the fear of fat is not a simple phobia, but a complicated disturbance of self perceptive regulation that needs understanding attention, slow building of trust in small steps (nutritional and psychotherapy), and restoring of hope and morale for the possibility of another approach to daily living.

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cjan: I am a recovering bulimic and would be interested in more information on relapse prevention. I went over a year without symptoms of bulimia and then relapsed a year ago. I am really worried about relapse.

Dr. Blinder: We are just completing a national, multi center study of SSRI (Prozac) in bulimia nervosa relapse prevention. The data will be analyzed in the next 6 months and the results available next year. Subjects received medication or placebo for 1 year, following their initial excellent response to the medication. The relapse rate was then measured for each group. Unfortunately, I can't report impressions or results at this time.

Dewdrop: Is drug treatment truly necessary? It is almost as if you are drugging them to get them to stop purging, etc. Shouldn't they learn on their own?

Dr. Blinder: Medication really helps by reducing carbohydrate craving, meal size, food on the mind, depression, and obsessional/ritual behaviors. Along with cognitive behavioral interventions and other psychotherapies, the patients appear to have a better chance to succeed in self regulation. Studies showing the effectiveness of psychotherapy alone, I believe, have limitations in their design and convey the wrong impression of the seriousness and suffering of this illness.

Boofer: I have found that the need to purge comes when I feel fear or extreme anger. If I cannot express these feeling, I tend to purge. Is there a common factor to these feelings in bulimia?

Dr. Blinder: Mood-linked eating disturbance is very common. Triggers are detachment, depression, anxiety, anger. The way this operates is complex---through mental images/memories and a complicated connection to the neuro hormones which stimulate and inhibit feeding. [see the paper: Eating Disorders in Psychiatric Illness, sited in the CV on my website]

Bob M: and we'll be giving everyone that address before the end of the chat.

Gloria: Dr., is there anything I can do to help a co-worker? Many of us worry and care very much about this person, but don't know the best way to help.

Dr. Blinder: Sometimes "gentle" intervention-like methods are helpful involving friends and family often arranging for the presence of a professional, if feasible. Giving the person understandable written information, reference to a personal published memoir or even websites that are informative. Starting with a physical exam can often be a less threatening initial pathway to treatment.

Bob M: By the way Gloria, Amy Medina- who is actually "Something Fishy" will be here tomorrow night to share her battle with anorexia...which should give people an insight to what an eating disorder is all about. Her battle continues to this day. Here's an audience comment re: the ongoing struggle:

Marge: I was at The Rader Institute for ED's in L.A. for 3 weeks. It helped, but only for awhile. Now I'm back where I started, or worse.

Bob M: If I understand what you said earlier Dr. Blinder, even if you get treatment and have dealt with your eating disorder successfully for awhile, you really need to continue on with therapy and monitoring to "keep it under control"? Am I right about that?

Dr. Blinder: Absolutely correct---it is a long, arduous, and sustained process---courage and family support is crucial.

Dan15: I am a 15 year old male. I was anorexic for 6 months before I started an out-patient program just before Christmas. I have been eating very well, but now I am supposed to add the "BAD FOODS" to what I eat (candy, cake, cookies, pie, etc.). I tried to do this, but I don't like the feeling I get when I eat them. I don't feel guilty about eating it. I don't know what I feel. It is like I don't know how to enjoy it. Any suggestions?

Dr. Blinder: Nutritional rehabilitation is now both a science and an art. You need to work carefully with the nutritionist to increase food selection in small steps (food mixing helps, going over previous favorites). The relationship should be one of teacher-mentor-friend with trust and honesty. The American Dietetic Association has some very valuable steps and guidelines for working with a nutritionist in eating disorder rehabilitation.

Joanne: What do you do when your sibling rejects you when you engage in purging, refuses to understand the illness because she believes it is unacceptable and all in the sufferer's hands to stop?

Bob M: And that goes for not only those who have an eating disorder, but for those with mental illness in general. They are rejected by family and friends. What's your suggestion on dealing with the rejection, the isolation?

Dr. Blinder: We call it "stigma"--very common in all psychiatric illnesses. Sometimes families are judgmental, rejecting, critical, and withdrawing. They must be forgiven ultimately. Then educated slowly, gently, about the realities of the suffering and the difficulties with free choice of control in these illnesses. Family therapy helps and should be a part of all intensive treatment efforts. Putting the family in touch with NAMI and other family support groups can be helpful.

Bob M: I know that time is moving on. One thing I want to touch on is your research programs. Can anyone with an eating disorder enroll in your research programs. If so, how? And do they get free, effective treatment out of it?

Dr. Blinder: The research programs vary with specific enrollment criteria, exclusion criteria and time limits. In general, some continued treatment is funded, but often this is very limited, unfortunately.

Champios: Is residential or in-patient treatment your recommendation for most patients? I'm a bulimic that is working on recovery without the help of therapists or counselors and wanted to know your opinion.

Dr. Blinder: Residential treatment is only necessary as the first phase of an intensive treatment attempt where other treatments have failed, or chronicity, psychiatric co-morbidity, medical complications and complex developmental factors work against any reasonable chance for success of an outpatient approach.

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Donnna: Dr, is the drug, Remeron, known to help with eating disorders? I've been suffering with both for 25 years and I am very tired of the illness. What can I do?

Dr. Blinder: I know of no published studies involving Remeron (mitrapazine) in eating disorders.

Jessa: Can I train my children not to eat to comfort themselves?

Dr. Blinder: Children derive satisfaction from many social, game, and educational activities. Differential reinforcement of these other activities can be done tactfully and gently, giving children alternatives to eating. Peer influence is important in determining eating choices and behavior of children. It might be useful to find a friend with better habits and invite them over.

Donnna: How can you begin to unlearn the behaviors of bulimia when they have become an automated response to almost any situation?

Dr. Blinder: I know of no published studies involving Remeron (mitrapazine) in eating disorders.

Maigen: I'm 16 and have recently been put on Prozac for bulimia. I didn't like the side effects and I stopped taking it. Are there any other effective drugs that you know of in the treatment for bulimia, that don't have the side effects that could interfere with my "daily female teenage life?"

Dr. Blinder: Any of the other SSRI's (Paxil, Luvox) might under careful supervision be tried. If the side effects are related to serotonin they are likely to recur, unfortunately. The new generation of medication in the next 2-3 years may hold promise for bulimia and ultimately replace the SSRI's. Some of our early studies involved norpramine which was found to be effective, but has its own side effects including cardiovascular dangers, which can be worsened by low potassium from purging. Consult an informed psychiatrist for further options. Bob

Bob M: Would you like to give us your website address Dr.?

Dr. Blinder: http://www.ltspeed.com/bjblinder

Bob M: I know it's late. Thank you very much for coming tonight and staying with us. 

Dr. Blinder: Thank you, it was my pleasure and privilege.

Bob M: Good Night.

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Dr. Brandt is our guest, and he will be talking about eating disorders.

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 are eating disorders 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 illnesses 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.

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Bob M: Here are some audience questions Dr. Brandt.

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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 for eating disorder 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 (eating disorder 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.

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.

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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 a while 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 for eating disorders treatment. 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 eating disorder 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. 

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.

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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.

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 eating disorder 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. 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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Bob M: Good evening everyone. I'm Bob McMillan, the moderator for tonight's eating disorders conference. Our topic tonight is Eating Disorders Diagnosis and Treatment. Our guest, Dr. David Garner, designed the test. He is the Director of the Toledo Center for Eating Disorders and a well-known researcher and treatment expert in the U.S. Dr. Garner is also one of the founding members of the Academy of Eating Disorders. Good evening Dr. Garner and welcome back to. Can you please start by telling us a bit more about your expertise in the area of eating disorders and then we'll move on from there?

Dr. Garner: Hello. I have had about 20 years of experience in research as well as clinical practice in the area of eating disorders.

Bob M: What does a clinician like yourself do to determine whether a person actually has an "eating disorder" or whether they have some disordered eating behaviors that aren't all that significant?

Dr. Garner: The key way to determine if someone has an eating disorder is by a careful clinical interview with questions directed at the main symptom areas.

Bob M: As you can imagine, several hundred people have already taken the Eating Attitudes Test on our site and they report back that the test indicated they have a significant area of concern. Is that all it takes?

Dr. Garner: The Eating Attitudes Test (EAT test) does not give a diagnosis, but it does provide valuable information on the levels of eating concerns typical of an eating disorder.

Bob M: For those just coming into the conference room: Our topic tonight is Eating Disorders diagnosis and treatment. Our guest is Dr. David Garner, Director of the Toledo Center for Eating Disorders. Dr. Garner is a highly respected professional in his field and has been involved in research as well as treatment of all eating disorders--anorexia, bulimia, compulsive overeating. There are many people who are self-diagnosed with an eating disorder. How important is it to get a professional evaluation?

Dr. Garner: A professional evaluation is essential, particularly a professional who has experience in the diagnosis and treatment of eating disorders.

Bob M: Dr. Garner can only be with us for about an hour tonight...so if you have a question or comment for him about any eating disorders related topic, please submit it now. I know the Toledo Center for Eating Disorders is an out-patient eating disorders treatment center. One question I always get is: what is the big difference, treatment wise, between in and out-patient. And how do you know which one to pick?

Dr. Garner: Inpatient provides complete structure and 24 hour supervision. Intensive Out-patient is about 35 hours a week at our center. There are advantages and disadvantages to both. I think that you want to pick the type of eating disorders treatment that is sufficient to get control over symptoms, but not more than you need. The advantages of an intensive outpatient program, IOP, is that it is less expensive and it provides practice every day with living in the real (non-hospital) world. In an IOP, you have 7 hours of treatment, but you also have time outside of the clinic setting to address the "out of hospital" world.

Bob M: The Toledo Center for Eating Disorders sponsors us. We asked them to sponsor the site because many of you, our visitors, asked for professional treatment, but wanted a great place to go at a more affordable cost. The Toledo Center for Eating Disorders is just that. They are located in Toledo, Ohio. If you go there, they can hook you up with some affordable housing during your stay. Here are some audience questions, Dr. Garner:

LOSTnSIDE: For someone who is an abuse survivor, is it at all possible to gain control of an eating disorder without having to bring up the misery of your past? Is it true that you can't fix one without the working on the other?

Dr. Garner: I have seen abuse survivors whose recovery is dependent on dealing with the abuse and others who really do not require delving into this issue. It may be important in its own right, but not essential to recovery from the Eating Disorder. This is a great question and the answer is that both approaches are sometimes best.

mleland: What are the strengths of the Toledo Center for Eating Disorders? (I've been to Laureate)

Dr. Garner: Laureate is an excellent program. We are smaller and provide a somewhat different orientation to treatment. The Toledo Center for Eating Disorders has a broad cognitive behavioral orientation as well as a strong family therapy component. We also emphasize nutritional counseling and a strong focus on group psychotherapy. And we don't use a "cookie cutter" approach of "one treatment fits all."

shade123: I have a daughter who is anorexic. How do I get her to consent to help? She is 36 and is severely underweight right now, in a lot of emotional trauma.

Dr. Garner: The best that you can do is to tell her that it is your view that she should absolutely seek treatment. However, she is an adult and she has to make the decision. Sometimes it is useful to think of how you would convince someone to seek treatment if they suffered from another disorder like alcoholism. Sometimes it helps in thinking through what you might do.

Bob M: We have nearly 100 people in the room right now. I'm going to set a one question per person limit.

chrissyj: Could you please give a little overview of an average out-patient day for a purging and restricting bulimic?

Dr. Garner: The average day consists of a review of the evening before, preparation of lunch with staff, group treatment, possibly a brief individual meeting to identify important issues, another group with a different theme, snack, dinner and perhaps some movement therapy- yes a lot of structured eating and a lot of therapy.

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ack: What if you are not physically "sick" enough for inpatient eating disorder treatment, but feel that you are emotionally "sick" enough.

Dr. Garner: I think that your opinion is very important and that you may need more structured treatment. Again, this is an example of where perhaps Intensive Outpatient Treatment could be helpful. It is more than outpatient and not as expensive and structured as inpatient. The important question is: what are the details of "feeling sick". This needs to be discussed with someone who has expertise in evaluating and treating eating disorders patients.

Bob M: By the way, with everyone asking treatment questions, how long does it take, on average, to recover from bulimia and anorexia? And is one easier to recover from vs. the other?

Dr. Garner: It takes about 20 weeks on average to do well with Bulimia Nervosa. The treatment for Anorexia Nervosa is longer and sometimes can last as long as 1-2 years.

Bob M: If you haven't taken the Eating Attitudes Test on our site yet, please do. It will give you a good starting point in evaluating yourself. The 20 weeks figure, is that in intensive treatment to make significant inroads towards recovery?

Dr. Garner: Actually, for bulimia nervosa, treatment usually can be conducted on a strictly outpatient basis. It is only very resistant cases that need to be seen in intensive outpatient treatment and inpatient is rarely needed unless the person is underweight. Our IOP is usually 6 to 12 weeks and is usually best for those who have to gain weight as part of treatment.

UgliestFattest: My therapist says that I am "painfully thin," but I just do not see it. How can I train myself to see what others see to me? I think I could stand to lose at least 20 pounds?

Dr. Garner: Unfortunately, recovery does not occur by you "seeing yourself more normally". The so-called body image disturbance that your therapist is talking about is "corrected" after you have managed to gain the confidence to gain weight.

Renie: My mom had anorexia when she was a teenager. Is it hereditary? Can I still have an eating disorder if I eat and don't throw up?

Dr. Garner: There is some evidence of genetic influence, but this does not say anything about what is needed for recovery and should not cause you to feel hopeless. Many disorders have a biological contribution, but the treatment is psychological. You can definitely have an Eating Disorder, like anorexia nervosa or compulsive overeating, and not vomit.

Anitram: Dr., I hate my body and want to be 95 lbs. I am 5 ft tall, and a college athlete. I took the EAT test (Eating Attitude Test) and scored a 52. I often think about purging, but never actually did it the way it is normally done. I have only done it a couple of times. What do you think about all this?

Dr. Garner: A score of 52 is very high. That combined with what you have said makes me very concerned. I think that you should consult an experienced professional. 

Shy: How does a person with anorexia know when they are bad enough to be considered for an outpatient program?

Dr. Garner: The best way to begin is with a in-person or a phone consultation. If you have anorexia nervosa, then you should !!! be considered for an outpatient program. Perhaps an intensive OP program. The complications for Anorexia are significant. The recent evidence on osteoporosis is really of concern and this disease continues to take its toll all of the time you are underweight. Thus, treatment should not be delayed.

Bob M: I didn't know that. Is there research now available that says an eating disorder can lead to osteoporosis?

Dr. Garner: Very convincing evidence. Bone mass decreases with weight loss and once you have lost bone, it does not come back.

Bob M: Let's say you are not desperately ill. Are there any physical symptoms that would clue you in that you need help immediately?

Dr. Garner: If you lose your period, it may not be evident to others that you have a problem, but it may cause osteoporosis and long term complications associated with this disorder.

twinkle: 5 months to recover!! What is the percentage that stay recovered??

Dr. Garner: "stay recovered" is not completely clear since people should be followed for years. However, 70% of people do very well after a course of treatment. Of those who completely follow the treatment advice, most recover.

bean2: How can I prevent a relapse. I feel like I am on the verge of one but I feel like I need to lose like 40 pounds. Any suggestions?

Dr. Garner: bean2: The wish to lose 40 pounds is a "give away". These types of thoughts may indicate a problem. You should speak to someone (an experienced professional) about this. It is like an alcoholic trying to prevent a relapse by going to a bar.

Bob M: One thing we've learned from the various eating disorders conferences is: trying to recover from an eating disorder on your own, without any professional treatment and support is very difficult, next to impossible.

Dr. Garner: That is correct. You need an experienced guide (a professional) on order to have the best chance to recover.

jack: Is having your significant other involved in recovery/treatment of your eating disorder imperative?

Dr. Garner: Yes, having your significant other is very important. Maybe not essential, but a good idea.

Bob M: One last question. We hear about intensive treatment programs that last 2-3 weeks. Do you think that is effective, or can be effective, when it comes to true recovery or is that a waste of money?

Dr. Garner: Personally, I would like to see the research that says 2-3 weeks can have an effect. This sounds more like something that is being dictated by insurance companies rather than by informed professionals. Where have you heard about this type of treatment for an eating disorder (2-3 weeks)?

Bob M: Several people have come to our site and said they went to a treatment program for less than a month, came out, tried hard on their own, and relapsed. And yes, some of them couldn't stay because of insurance problems, but for others, the program only ran 2-3 weeks.

Dr. Garner: I am not surprised. It is terrible when insurance determines treatment rather than the needs of the person with an ED. Are there really programs that actually run for 2-3 weeks. Where is the research on this type of treatment?

Bob M: We appreciate you coming tonight Dr. Garner. I know you have to go now. And thanks everyone in the audience for coming and participating. Have a pleasant evening.

Dr. Garner: Thank you very much for having me as a guest at your eating disorders conference. I want to wish all of your participants the best in their efforts at overcoming their eating disorder.

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Bob M: Good Night everyone.

Bob M: Good evening everyone. For those of you who are new to the Concerned Counseling Website, welcome. I'm Bob McMillan, the moderator for tonight's conference. Our guest is Dr. Steven Crawford, Associate Director of the St. Joseph's Center for Eating Disorders. Our topic tonight is: What does the word "recovered" really mean when it comes to an eating disorder. And coping strategies for families and friends and how they can best help the eating disorder sufferer. I want to welcome Dr. Steven Crawford back to our chat site tonight. Before we get to the questions Dr. Crawford, maybe you can tell us a bit more about your expertise in the area of eating disorders?

Dr. Crawford: I am currently the Associate Director for the Center for Eating Disorders. I have worked closely with Harry Brandt, MD for the past ten years treating individuals suffering with eating disorders. I appreciate the opportunity to be here this evening to discuss the process of recovery.

Bob M: What exactly does the word "recovered" mean when it comes to eating disorder patients?

Dr. Crawford:Eating Disorders Recovery is not easily defined. It is individualized in many ways. Recovery is a process and not an event. Eating disorders do not develop overnight and are not "cured" overnight. Simply stated, eating disorders recovery is most likely achieved when an individual is able to not have food dominate their every waking moment. Individuals moving toward recovery are able to engage in social activities, work, school, etc. without having their concerns with eating decrease their functioning.

Bob M: So are you saying, "recovered" is not the same as "cured". Even if you have "recovered," you will still have eating disordered thoughts or behaviors, you will just be able to control them better than before?

Dr. Crawford: Yes. Many individuals have told me that they see eating disorders recovery as a daily choice to not act on their symptoms and that they are never completely free of concerns about their weight and appearance. However, they have learned to live with these concerns in such a way that they do not limit their lives.

Bob M: Is that why even someone who has "recovered" is always at risk for a relapse?

Dr. Crawford: Yes. Individuals who have moved toward recovery remain at risk for relapse throughout their lives. This is because they have learned to use their eating disorder symptoms as their means of coping and during times of stress, people tend to revert to comfortable means of coping.

Bob M: We have many people in the audience tonight, so I'm going to get to some audience questions on this part of the conference early. Then we'll move on to helping family and friends cope and how they best can help someone they know handle their eating disorder.

Bry: Is the recovery process the same for all Eating Disorders?

Dr. Crawford: In many ways, yes. Treatment is essential to recovery from all eating disorders. Individuals need to take a two-track approach to recovery. The first track is learning to block eating disorder symptoms. The second track is beginning to understand what is underneath the eating disorder. Both tracks are important and necessary. Developing control over the symptoms usually entails nutritional counseling, with moving towards normalization of eating. It can also include medication management. At times, partial hospitalization and inpatient treatment are necessary to assist individuals in symptom blockade. Understanding what is underneath the eating disorder involves psychotherapy, either individual, group, family or a combination of the above. Support groups are also helpful.

windwood: Dr. Crawford, I have managed to keep from binging and purging or complete restricting for at least 7 years now (after having been anorexic and bulimic for nearly a decade). But I must admit, I still have thoughts of wanting to be thinner. I am in no way overweight. Is it truly possible to stop this nonsense thinking?

Dr. Crawford: As I said earlier, learning to live with the thoughts, and not acting on them, can be a lifelong process. It sounds as though you have achieved this. I sometimes suggest to patients that their eating disorder can actually be helpful. When the thoughts feel stronger and more difficult to control, it can be a red flag that there are stressors building in one's life that need to be tended to.

Elora: When is it imperative to get help?

Dr. Crawford: I suggest that when the eating disorder is interfering with one's lifestyle that it is time to get help.

Bob M: I want to take the time to mention here, that one of the people who frequently visited our website and chat rooms died last week from her eating disorder. She suffered a heart attack. I want to encourage everyone here tonight, that if you are suffering from an eating disorder, please get professional help. This is not something that you will be able to beat by yourself. And I want to stress, as so many of our previous guests have, the longer you wait, the harder it is to recover.

Cie: I heard that in St. Joseph's you almost "force" patients to socialize and keep out as much private time as possible to patients. Is this crucial to recovery and what is the theory behind it?

Dr. Crawford: During hospitalization, patients need to be monitored closely to assist them in not acting on their eating disorder. "Private time" may leave vulnerable individuals with an opportunity to act on overwhelming eating disorder impulses.

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Bob M: We are going to take a few more questions on the subject of "what is recovery" and then move onto helping family and friends cope and how they can help someone close with their eating disorder.

AshtonM24: I'm Anthony and I'm an Anorexic. I am 27. I am also the Connecticut contact for the American Association for Anorexia Nervosa and Associated Disorders. (ANAD). What would your opinion be of a Serious Clinical Trial using THC, marijuana, as an appetite enhancer for the beginning stages of medical weight restoration in the early part of treatment for anorexia nervosa?

Dr. Crawford: This was actually done in the late 1970's at the National Institutes of Health. Appetite stimulants actually increase the anxiety of persons with anorexia. Further, marijuana is a potent Central Nervous System depressant. This strategy to deal with anorexia does not work and is ill advised.

Shy: When a person starts going through the eating disorders recovery process and has a setback, could the setback be worse than the original problem?

Dr. Crawford: Yes. Commonly the disorder progresses with periods of illness and periods of improvement. However, when people do relapse, the disorder can progress and be more disabling.

LDV: After 20 years of eating disorders, is recovery possible?

Dr. Crawford: Yes. I have seen patients recover who have been ill for decades.

Chrissyj: Is there a certain amount of time people have to not think about food to be recovered? Like cancer remission?

Dr. Crawford: Recovery is a process and individuals who have struggled with eating disorder thoughts and behaviors often still have some obsessional thoughts about food, weight, and appearance even after they are heading toward recovery.

Maureen: Do eating disorders seriously hurt your heart?

Dr. Crawford: There are a number of cardiac problems that can result from starvation. However, most resolve with normal eating behavior and weight gain. If you are having any symptoms such as shortness of breath, fatigue, palpitations, irregular heart beat, chest pain, etc., you should see your physician ASAP.

Bob M: For those just joining us, our guest is Dr. Steven Crawford, Associate Director of the St. Joseph's Center for Eating Disorders. Our topic tonight is: What does the word "recovered" really mean when it comes to an eating disorder. And coping strategies for families and friends and how they can best help the eating disorder sufferer.

wickla: How does a person take the first step? Where can they go? What will happen?

Dr. Crawford: The first step is acknowledging that there is a problem. Then they must be willing to accept help from friends, family, and professionals.

Bob M: I get emails everyday from family and friends of those with eating disorders asking what can they do to help and how difficult it is for them to cope. The second half of this conference will concentrate on that. I can only imagine how difficult it must be for parents, siblings, husbands, wives, and children who are in the same house as someone with an eating disorder. As I mentioned, I get letters from these people everyday talking about how their lives have been impacted. What can they do to cope, Dr. Crawford?

Dr. Crawford: First, and most importantly, family and friends need to be patient. They need to recognize how powerful an eating disorder can be. They need to remember it is an illness and that the individual needs compassion. Family and friends can support the individual in getting treatment and may consider getting help themselves, if needed. Finally, asking the individual how one can best be helpful is an important step.

Bob M: From some of the letters Dr., it seems it's very frustrating for those who are close, when they tell the person "you need to get help" and they don't. How would you deal with that?

Dr. Crawford: We generally suggest to the person that they tell the patient that nothing can be lost from getting some professional input. They may find out that they don't have a problem, but when others are concerned often they do.

Bob M: I understand. But how are those close to the person with anorexia, bulimia, or a compulsive overeater, supposed to cope. What tools can you give them?

Dr. Crawford: First, it is important for friends and family to recognize that while they can provide access to treatment, and support treatment, they cannot recover FOR the individual. We recommend that family members and friends develop their own coping mechanisms and support structure. In our area, many family members benefit from our open support groups, where they do not feel as alone.

nholdway: How should a friend answer the constant question of "Do I look fat?"

Dr. Crawford: I would tell the individual that there is no good answer to this common question. If they were to say "no," the individual will likely discount the response. I would encourage the family member to confront the patient's continual over focus on body shape, weight, and appearance. In general, it is best to avoid conversations related to these topics.

Shy: Every afternoon when I get home, when my husband asks me if I have eaten that day and I tell him the truth, which is usually no, he acts like he is depressed about it and doesn't speak to me the rest of the evening. How do I handle this?

Dr. Crawford: Perhaps he withdraws because he is concerned about your health. If you avoid eating because of fear of weight gain, you have a problem that warrants your serious attention.

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AnnMarieg: As the husband of a 20 year bulimic, what's my best approach when severe depression sets in?

Dr. Crawford: For the patient or for you?

Bob M: Dr. Crawford, I believe this person is the husband...and is speaking about his wife-who is a long-time bulimic patient. How does he deal with his wife's depression?

Dr. Crawford: I was genuinely wondering if he was wanting help with the depression that family members often feel, or whether he wanted strategies to deal with his wife's depression. I'll address both. First, the husband should try as best he can to recognize the signs of depression in his wife and he should try to be as compassionate and understanding as he can. He should try not to be judgmental, although this can be quite difficult at times. He should encourage her to follow the treatment program that has been developed by her care providers and he should try to avoid power struggles and conflicts related to food and eating. Most importantly, he should constantly remind himself that his wife has a serious illness and she lacks certain controls at times. In terms of his own depression, he should recognize that the chronic stress of a serious illness in the family can take its toll, and no one is immune from depression. If significant symptoms are present, he should seek help right away.

Ann: Is it often that someone with an eating disorder has a co-conspirator, and should the co-conspirator be kept away from the recoveree?

Dr. Crawford: It is not uncommon for persons with eating disorders to get together and defensively support the illness in each other. This is a real problem, but usually, deep inside, the patients know what is going on.

Bob M: An audience member wanted me to ask this question very directly: Since no one can make another person do something they don't want, like go to a doctor for treatment, for their own sanity, should a family member/close friend just say "the heck with it" and go on with their lives? After all, what more can you do if you've encouraged the person to seek help and they don't want to get it?

Dr. Crawford: I wouldn't give up easily because many times patients are in stages of denial for months, or even years, and suddenly turn the corner and recognize that they have a serious problem. I do think that family members need to meet their own needs and not let the eating disorder ruin their life too. This is one of those "fine line" issues where one needs to strike a balance between "appropriately concerned," but not "consumed".

Jenshouse: Would it help someone to get treatment if you offered to go with them or is that not a good idea?

Dr. Crawford: Patients are often brought in by supportive friends who are quite helpful. Frequently friends and family will attend our support groups with the patient.

Bob M: Here are two similar questions:

SilverWillow: I think that I have an eating disorder and I am seriously thinking about seeking some help, but my boyfriend/fiancé doesn't know anything about this. I am frightened to let my secret out, but I really think I need some help. Should I tell him about this? If I do decide to tell him, can you suggest a "gentle" way to break the news?

Keensia: How can I tell someone that I have an eating disorder?

Dr. Crawford: Our view is that being secretive about an eating disorder is a sign of avoidance and denial. If your boyfriend genuinely cares for you, he should accept you as you are, but also should support you toward a healthier life. We believe that honesty is the best policy.

smiup: As a parent of 17-year-old daughter with an eating disorder, what are the chances of this being a phase teenagers go through, like drinking or drugs?

Dr. Crawford: I would fear that viewing the problem as a "phase" might be a way to minimize the seriousness of it. However, many adolescents with eating disorders do recover in adulthood. Many adolescents are very concerned about body image and weight, but do not have a full syndrome. If these symptoms are interfering with everyday life, then help is needed.

Bob M: Here are a few audience comments relating to what we are talking about:

LDV: When my husband comes home from work and asks about the food? he thinks I am not trying when I can't eat.

LMermaid: My wife has anorexia and admits this but will never, ever admit that she is depressed and this has contributed towards her not taking meds which are linked with Serotonin reuptake. Should I be convincing her she is depressed or supporting her stand? She does seem depressed to me from time-to-time, due to her eating disorder and complications stemming from it.

Dr. Crawford: The medications can frequently be helpful for anorexic patients regardless of whether depression is present.

Bob M: It's getting late. Thank you Dr. Crawford for coming tonight. And to everyone in the audience, thank you for your participation and your questions. I want to again urge everyone...if you need help recovering from you eating disorder, please take it seriously.

Dr. Crawford: Thanks, Bob. As always, I've enjoyed being part of the conference.

Bob M: Good Night everyone.

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Bob M: Good evening. I want to welcome everyone to our EATING DISORDERS RECOVERY conference and to the Concerned Counseling website. I'm Bob McMillan, the moderator. Our topic tonight is EATING DISORDERS RECOVERY. Our two guests are "normal" people, not authors of a book, or some celebrity type. I bring that up because both have "recovered" from their eating disorders, but the ways they did it were very different. Our first guest is Linda. Linda is 29 years old. Our second guest is Debbie, who is 34. I'm going to have each give us a little background on themselves and how their disorder started. And then move quickly into their recovery stories. Because I'm anticipating a large crowd, I'm going to limit the questions to 1 per person. That way, everyone gets a chance. Linda, I'd like to start with you telling us a little about yourself, which eating disorder you had, how it started, etc.

Linda: Well, let's see. I am the youngest and only daughter of two doctors. I went to private schools (girls' schools) and took ballet. I think all of that helped "foster" my eating disorder. I "dabbled" a little in anorexia, but found the restricting very difficult, especially because I needed some energy to dance. I struggled for about seven years with bulimia. It wasn't until I moved out of my house (dysfunctional family - bad relationships) and took a real good look at my life, that I chose recovery. I think I knew that what I was doing was unhealthy and dangerous, and that I couldn't live a long and prosperous life that way. But I think I also knew that I couldn't recover while I still lived with my parents. By the time recovery began, around age 21, I knew that it was what I wanted, needed and that I was ready for it. There were very little resources or knowledge in the medical community. There were no support groups, and only one clinic with four beds. I read books voraciously...books about eating disorders, about recovery, about spirituality...and aside from that, for the first year, all I did was see an MD. When I first told him what was wrong, he said," I'm the doctor. I make the diagnosis." Of course, I knew better about the whole thing than he did. I did join a support group about a year later. I had stopped completely bingeing and purging after one and a half years.

Bob M: At the worst point Linda, how bad was it for you? How much were you bingeing? What was your medical condition like?

Linda: I actually prefer not to mention numbers, even in a forum like this. Binge eating/purging took different forms, and it was very often, many times per day and I was taking laxatives too. I was very lucky. Even today, there is no visible damage to my teeth, digestive tract, etc. At the worst point, when my weight was at the lowest, I was scared. I knew I couldn't maintain that and live. And with my parents being doctors, I had to be creative, trying to keep everything secret.

Bob M: Were you ever hospitalized Linda?

Linda: No. There was a time when my body "shut down" as I call it. I was tube fed at home for two or three days (a "bonus" to having parents as doctors). I couldn't keep anything down even if I tried. My body just voided itself on its own.

Bob M: If you're just coming into the room. Welcome. Our topic tonight is EATING DISORDERS RECOVERY. Linda (age 29) and Debbie (age 34) are our guests tonight. Both recovered from their eating disorder, but used different processes to do that. For tonight, since we have two guests, please type either Linda or Debbie at the front of your question or comment, so we know who it's directed to. Since the audience is so large tonight, I want to ask everyone to only send one question. We are going to try and get to as many as possible. Debbie, tell us a little about yourself please?

Debbie: My story. I'm an executive assistant to a very demanding boss. My eating disorder, anorexia and bulimia (later), started when I was 16. Like many girls that age, I just wanted to be wanted...by boys, of course. And I thought the only way that would happen is if I looked pretty, translated "thin". I don't usually bring up weights, but to put this in context, I was 5'4", 130 pds. Over the course of 3 years, when I was 19, I was down to 103 and thinking that wasn't enough. I was keeping my eating disorder to myself and one day when I was in college, a couple of girls in the dorm were in the bathroom and I heard one throwing up. And that's when I learned about bulimia. As you can imagine, or maybe for some of you, luckily you can't, my life was a wreck. My electrolytes went way down, I was hardly eating, and whatever I ate, I threw up. So my entire body one day just gave out.

Bob M: and this was over what period of time Debbie?

Debbie: I was 20 when I had my first hospitalization.

Bob M: We have a few questions and comments from the audience I want to get to. Then I want to hear your recovery stories.

jelor: Linda, did you ever slide back to your old ways, interrupting recovery? for how long? is that okay?

Linda: Yes. It did take me over a year-and-a-half before I completely stopped binge eating and purging. But it went from numerous times daily to once a week, to once a month, to finally-never. I felt it was a part of recovery, that it took me "xx" years to learn those negative behaviors, that it would take me a while to learn positive coping skills. I tried to make sure that I didn't rip myself apart for it. I forgave myself. It was ok.

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Jenna: Linda and Debbie, what truly *awakened* you to the fact that you suffered from an Eating Disorder? Do you two feel that you truly have to hit bottom before you can accept it?

Debbie: I was at the very bottom. When you can hardly walk because you are so weak, you're whole body aches, your stomach cramps and it feels like someone is ripping your gut from the inside and squeezing it, you don't need someone to tell you something is wrong. It was absolutely horrible. I'll tell you a little about my recovery, quickly, because it relates to this. I was hospitalized for the first time when I was around 20 because my medical condition was so bad. I was in the hospital for 2 weeks and finally able to go home. My parents then sent me to a treatment center in Pennsylvania. I was there for 2 months. And I thought I'd finally gotten control of this. I went home and not 7 months later, I was back doing the same things again. I tell you this, because for some of us with eating disorders, it is very difficult to break the grasp. Between that time, the time I went home, and the age of 28, I was in a treatment center a total of 5 times. The longest time for 6 months.

Bob M: Linda. What about you, did you hit bottom before you were able to get control?

Linda: For me, I hit my own rock bottom. Even below 90 lbs, I knew something was wrong. I gained a few more and stayed there for a few years. At some point, I looked at myself and thought 'what kind of life is this?' I could never please anyone. It didn't really matter to them anyways. I couldn't see myself at 50, buying laxatives or vomiting. I couldn't live like that. But I don't think one has to get that low, to that point of self-hatred, before one can begin recovery.

Bob M: Here are some more audience questions:

symba: Linda I need to know what got you out of this???? Please tell me!!!!

Linda: Symba, when I began eating disorder recovery, for me there was no other choice. I didn't look back. I took back my power from the scale, from the calories, and from everyone else and took ownership of it. I made peace with myself, with food, and with everything else that was once "bad" to me.

Bob M: Can you please describe your recovery process?

Linda: At the time, I had a wonderful partner. He was very supportive. He didn't know about my eating disorder. The day I told him was the first night I went to bed without purging or weighing myself in years. I searched and searched for support and didn't find any "professional" help. I told all of my closest friends, which gave me so much strength and courage. I had a book that was my "bible". I carried it with me for months. It was very inspirational. I was in an eating disorder support group more than a year after I began recovery and went into therapy about a year after that.

Bob M: I invited Linda and Debbie here tonight because they represent opposite ends of the recovery spectrum. Fortunately, Linda was able to recover without a treatment center...but not without help altogether. She was able to use the support from friends and her support group to help her through. I'm saving this question for Debbie.

tennis me: This is the same generic "gently described" type of recovery. What was the struggle like? I struggle to get better and no one understands how hard each minute can be.

Debbie: I do tennis me.

Linda: Me too tennis me.

Debbie: So you don't want me to pull any punches. When I went to the hospital for my medical condition, I was very scared. Imagine being 19 and thinking you're gonna die...that it's too late...and that all the times you said you were going to stop and get help, but didn't. Now it's payback time. I didn't have any friends who had an eating disorder and especially back then, people with eating disorders didn't go around telling anyone. It was really something to be ashamed of. When I went to the treatment center the first time, I can tell you I was very scared. I felt sick, disgusted by myself. I also didn't know what to expect. Was this going to be like a jail? An insane asylum for crazy people?

Bob M: Tell us what it was like inside, Debbie?

Debbie: Well, they watch over you all the time. They want to make sure that you actually eat and then also to make sure you don't throw up. It's not that it's a bad thing because if they didn't do that, you would just continue on with your eating disorder. The people there, the doctors, nurses, nutritionists and everyone were very supportive. I guess the only thing I can compare it to is like going through withdrawal, so to speak. And doing it cold turkey. Although to be honest, I've never had an addiction problem. I'm just trying to make an analogy. But as time went on, it got better. I was able to sort my problems out, define them better and deal with them in a more constructive way. I learned how to use various tools, like journals and support groups, to assist me in my recovery.

Linda: Yes. It is hard to let go. Sorry to interrupt...just had to throw that in.

Debbie: But it was very difficult at first. And for many of us with eating disorders, maybe one trip to the treatment center will not be enough.

terter: Do you think that an eating disorder is ever really cured or is it with us forever?

Linda: Yes, I believe it can be cured. I don't believe it is like an addiction, although I know some others who do feel that way. I think that an eating disorder is part of a huge continuum of disordered eating patterns, and that eating disordered behaviors are negative coping skills. I think we are taught to scrutinize ourselves and our bodies...to find fault, and to work against the body. I think it does take time to end the behaviors, and to learn to think differently and it gets harder as the messages in the media get more prolific. But I do think it is possible to recover 100%.

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Versus: Debbie, can you tell me if your hair fell out at all and if so what on earth did you do for it. Is eating less than 1200 calories going to "not" help?

Debbie: Yes! at one point my hair was very thin and wispy and was falling out. That's because my body wasn't getting the vitamins and minerals it needed. To be honest, there's really nothing you can do but start getting the food and minerals and vitamins you need. And keep in mind, I'm not a dr., but I've got a lot of experience. :)

Jenshouse: Debbie and Linda--I am 19. I am recovering from many different things from childhood as well as trying to get over this eating disorder. I am often depressed or angry, mad when in these states. It is the worst for eating. I can never seem to force myself to eat. I don't want to lose weight. I just feel that I can't eat. That I shouldn't eat. That I don't deserve it. How did you get yourself to eat something?

Linda: Whew.. that's a tough one! For me, I KNEW that my body needed the food. I KNEW I needed food to function, and that if I didn't eat I was no good to anyone, especially myself, in the end. For me, I learned to do it slowly. And I learned to enjoy what I ate; to TASTE it...something I hadn't really done in years. Debbie, what about you?

Debbie: I never felt like I didn't deserve to take care of myself. I started my eating disorder because I was unhappy with my shape and thought I'd be more attractive with the more weight I lost. Jen, I think everyone deserves a good life. If you have low self-esteem, which I found out I did, you need to get help and sort the things out in your life.

Linda: Good point, Debbie.

Debbie: And I noticed you said, you didn't "deserve it", that's a big clue that your thinking isn't the way it should be. And I want to say here, that even now, after 10 years of therapy and eating disorder treatment centers, there are still times when I have to remind myself that I am a worthy person. That I am likeable. That I'm smart and can make good decisions in my life. I think Linda wants to add to this.

Linda: Thanks Debbie. I think Debbie has raised a very good point. We ALL deserve a good and healthy life. No one is ever more deserving than another. But as I said earlier, it is a daily struggle to take care of one's self and look at the positives. As Debbie said, to know that we are all worthy. I think that there are a lot of negative messages out there, that help contribute to low self-esteem.

AlphaDog: I'm so scared. I have been through this many times. I am not doing well now. How do I stop starving myself?

Debbie: Alpha, it is a very difficult process. And for many of us, it takes a long time and a lot of work. I wish I could give you the magic cure, but for each person it can be different and take something different to get over it, to get a handle on it. I would hope that you are getting help, seeing an eating disorders' specialist. And also Linda's way, of going to a support group. It really works and it helps. I think we all need support. Getting over something like this on our own would be very tough.

bean2: Linda, what was the name of the book that you used?

Linda: "Bulimia: A Guide to Recovery" by Lindsey Hall and Leigh Cohn. It truly helped me save my life.

resom: Debbie and Linda -- I'm 21 years old and a former anorexic. I still get really nervous about calories. How do I eat out when I'm terrified of eating too many calories? I want to have a life again.

Linda: Well, as I said earlier, I don't look at numbers. That includes calories. It is important to know that the body needs lots (lots!!) of calories just to function. I gave up counting calories. That's part of how I 'got a life' again. Don't be afraid of food. And don't make it "good" or "bad". It is simply food. Enjoy it because we need it. Give yourself permission to do that, resom. Debbie?

Debbie: I don't weigh myself. I have one mirror in the bathroom which I use in the morning and evening when I clean up. At first, I always kept a book with what foods I needed to eat to make my "calorie count". But then as time went on, I was able to develop more "normal" eating patterns, but I still knew what I needed to stay healthy. Also, if you are having trouble going out, try and get your support group to go with you. That's what we did. Went out as a group. And all supported each other. Sounds silly, but it works.

Shy: Debbie, when a person is recovering, or starts the recovery process, is it important to have a counselor or therapist for help?

Debbie: I think so. I couldn't do it on my own. I needed someone to be there for me and to encourage me and soften the blows. It's very tough Shy. And I know Linda did it on her own, but as she said, she really had support too...right Linda?

Linda: That's right Debbie. I had great friends. Without them, I couldn't have done it alone. And as for therapy, I think it is a necessary step in recovery. There are definitely issues for everyone that go much deeper than food, weight and calories. Having others around, kind of "arms" you with strength.

Debbie: I know that all of us are pretty ashamed of our eating disorders and what they do to us. And that's why we don't tell anyone. But I'm here to say, it's important to tell people who really care about you. Their help and support is very important and will go a long way in helping with your recovery.

Linda: Yes, and their reactions are often not what you expect.

Debbie: And if you can't get to a therapist yourself, your parents or friends may be able to help with money or encouragement.

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Mosegaard: Debbie, did you get medication while you recovered? If yes, are you still on medication today? If no, how did you get off it?

Debbie: Yes, I was on at first, then Prozac later. It helped with controlling my bulimia. But as you can imagine, I was pretty depressed too. But the more therapy I had and the more I was able to work through my problems ("issues" for you professionals out there :), the more I was able to lower my med dosages and finally came off it. But if you have a chemical imbalance, you may not be able to come off. But again, I think that's something for you and your doc to talk about. And one more thing, I think medication without therapy is a rip-off. Medication doesn't get rid of your problems, it just masks the depression for awhile. But even with medications, you still have the problems and they are out there lurking, affecting everything you do. So you can't really "recover" until you resolve your problems.

Jamie: Linda, is three years too long to spend in recovery? Does that mean I am not serious?

Linda: No. I am certainly not one too judge either. As Debbie mentioned earlier, it is different for all people. I think that as long as you are working on recovery and trying to find positives, then that's good. Remember, it's about baby steps, and recovery will definitely not happen overnight. I think it also depends on what issues you may be dealing with, Jamie.

Bob M: If you're just joining us, welcome to the Concerned Counseling website and our conference. Our topic tonight is EATING DISORDERS RECOVERY. Linda (age 29) and Debbie (age 34) are our guests tonight. Both recovered from their eating disorder, but used different processes to do that. Linda utilized support groups and self-help books and had close friends help her. Debbie went to professional therapists and was in various treatment centers a total of 5 times in about 7 years. I think Debbie wants to add to Linda's comments.

Debbie: As youngsters, one of things we learn about medicine is, you go to the doctor, he fixes you, and you are better. What's it going to take-- a few days, two weeks, a couple of months, before I'm back on track? In real life, it's not like that. Some things, like cancer, or maybe an eating disorder, take longer, a lot longer. And there will be good days and bad ones. I think if you can think of eating disorder treatment as a continuum, as Linda said, that's good. And be realistic. You are getting help, you may have relapses, but you are expecting that and you know they have to be dealt with. And I think it's important to tell your friends or those in the support group ahead of time, "if you see I'm going to relapse or I'm having a hard time, please be there for me, don't let me slip too far down into that dark hole." And soon, the relapses are spread apart over longer periods and then eventually you are able to cope on your own. And Linda has another thing to say.

Linda: We've talked about 'relapses'. I think it is very important to repeat that recovery is not going to happen overnight. You may take five steps forward, and go backwards two steps. But then you go forward again. Be proud of those little steps forward, because it counts! And every step backward makes you stronger, gives you strength for the next time you may feel yourself going backwards.

Bob M: Here are some comments about medications:

PCB: I have been in recovery for 11 years. It is a steady process of ups and downs. I have also been on medication during this time due to a chemical imbalance. I was resistant at first, but now I know that I will need my meds for life. I have a quality of life that never existed before. The meds have stabilized my moods so that I can look at reality and face the issues in my life. I am calmer and more rational in my thinking.

Agoen: My doctor gave me a medication. She thought it would be a quick cure but it wasn't. It was hard enough for me to tell her about my eating disorder and I feel in some way she let me down. So I'm afraid to ask for help again.

caricojr: I think meds are necessary in some cases. You can't deal with problems rationally if you are extremely depressed.

froggle08: I don't think medication is a rip-off. For some people who don't need it it is, but for some people it can really help them a lot.

Bob M: Debbie, since you made the comment, how about addressing that.

Debbie: I'm sorry, maybe I didn't make myself clear. I'm not saying medications are a rip-off. What I meant was, if you are taking medication, it's also important to get therapy to help with dealing with your problems. I think that one without the other isn't good. And a lot of doctors today just hand out meds and say good luck. That's what I don't like. But that's my personal opinion.

Linda: I'd like to add something. I think that there is a "trend" today where the medical profession prescribes anti-depressants for eating disorders. I think that this can be dangerous. I agree that there are some cases where medications are needed, but I think it is wrong to automatically prescribe them. I think that if one is at low weight and has been depriving the body of important nutrients, then someone will be cranky and depressed. I also have heard of "natural" anti-depressants.

Bob M: I want to add here, that it is important to discuss these issues with your doctor, so you can make informed decisions. These next questions are all related:

Vortle: What is the best way to be able to tell people that you have an eating disorder? I told one friend who also has eating disorder and she's mad at me for not wanting to get better bad enough. We don't talk anymore. I can't get the courage to tell my family.

ack: What about the people in your life. I have had a terrible time trying to help my boyfriend with this. He just doesn't understand and I don't think he wants to. Is it necessary for your significant other to understand to have a healthy relationship?

Symba: How do I get my husband to understand this eating disorder? He doesn't want to. I try to talk to him and I feel I'm getting blown off.

Bob M: Linda, how were you able to confide in your boyfriend the first time?

Linda: For me, it was hard, and yet it was easy. He was someone that I loved and respected. I knew that our relationship depended on that, and that he loved me no matter what. I don't think all situations are like that. I am very lucky. I know that there are support groups out there for family members and friends of people who struggle with eating disorders. I think that your partner has to be supportive. Understanding ED is hard, and may not happen. I think you both have to work at it on some level from the same or similar view, or the relationship may not withstand it.

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Debbie: Now that I've been through a lot and I've been able to sort of look back, like I said earlier, I think it's difficult for our friends and family. They think "go to the doctor, get better". It's that simple. It isn't. That's why eating disorders support groups are so important. You are around people who do understand and can encourage you. And Linda's right, it can put a lot of tension in a relationship. I had several end "before their time", so to speak. All you can say is "look I need your help and support". And at the treatment center, when they get family therapy going, the therapist tells the parents that this will be very stressful on them and there's no shame if they need support. And usually they do, depending on how difficult things are.

sizeone: I think it goes without saying that family members are just scared and do not know what to do with someone they think is great and in reality, that person hates themselves.

caricojr: A very good book that saved my boyfriend's and mine relationship was "Surviving an Eating Disorder : New Perspectives and Strategies for Family and Friends".

Linda: I'd like to say something about family. I think there are some cases (like mine) where families were not involved in the recovery process. I know some people have huge issues with family. For me, my doctor parents, it was not an option. They knew, but never talked about it. It was scandalous. And that is scary, and it is a shame. I know some people are afraid of disclosing to their families, for whatever reason. And that's ok. You don't have to. If you are in a treatment center, then obviously they know. To this day, I have not talked about it with my parents. I have made peace with that and let go of the fact that they could never understand.

blubberpot: I feel the same way about my parents. They think my eating disorder is a thing in the past, but what they don't know, is that I have lost another 11 pounds.

Rod: Is it wise to attempt to have a relationship while in treatment for an eating disorder, or should we wait until we are better?

Linda: For me, I was in a relationship already, for about two years. It added a new dimension to our relationship. I think that you should do what you feels right. I think that if you want to start a relationship, that you should be honest with that person. Debbie, what do you think?

Debbie: That's a trick question. I found out it was easier for me to deal with my problems when I didn't have a significant person, i.e. boyfriend, in my life. It just got to be too difficult, trying to handle a relationship and it's normal demands and expectations, and deal with my eating disorder. But I'm sure for others, it can be a very supportive and helpful thing. I agree with Linda though, I think you have to be honest with the person and do it up front. Don't wait until you are 3 months into the relationship and say "SURPRISE!!", by the way, did I tell you....because I promise, most won't be happily surprised. That's from experience, by the way.

Monmas: My husband seems to leave the healing to me and my therapist. He never gets involved with my eating. This makes me angry at him sometimes. It makes me think he doesn't care. How can I get him to be supportive, yet not tell me how to eat?

Linda: Tell him what you need. We need to do that in all areas of our relationships. We NEED support, we need space, we need a hug. Sometimes we need to ask for it. Maybe he is scared and confused about it too?

Monmas: Yes, I think he is. I try to tell him how I feel, but he doesn't understand the whole picture, so he doesn't want to say the wrong thing. He loves me very much though.

Bob M: It may be he doesn't know what to do. If he hasn't participated in group therapy or some sessions with you, he may not understand his role in your recovery.

Debbie: It's hard to tell monmas. I would talk with him and tell him what you need. And then see what happens. Make it non-threatening though. Don't say "you never help me." Try, I need your help, could you please do this for me." I hope that helps some.

gutterpunkchic: I am going to be going to my first therapy session on Friday. I am just starting to realize I need help, but I am afraid it will take me a long time to recover. What do I do if therapy doesn't work for me?

Linda: gpc, there are many different kinds of therapy out there, and many, many different therapists. It is important not to give up, even if it feels exhausting. Remember that you are a consumer of the health care system, and you are entitled to get the help you need and want. If you don't like your therapist, find another. Also, as we've said, support groups are very helpful, and are very different than therapy. Debbie?

Debbie: I think it's important to remember gutterpunkchic that it may take awhile. Maybe you will "grow" as time goes along and you will be more receptive to therapy or able to deal with things in a better way. But give it time. It won't happen "just like that". And like Linda said, what works for one, may not for another. So you may have to find another therapist or method of treatment. But give it time.

Bob M: We had over 100 people come tonight. I appreciate everyone being here and to Linda and Debbie thank you for sharing your stories and staying late to answer questions.

Linda: Thanks Bob.

Bob M: I hope that everyone got something positive from tonight's conference and that you feel like there are many ways to recovery. And that you need to find what works for you. It also helps when you have others who care around you.

Debbie: Thank you Bob for inviting me tonight. For everyone out there, I was at death's door. I'm not a rocket scientist and I don't think I was the beneficiary of a miracle. It was a lot of hard work and I cried a lot and thought many times about giving up. I hope you have the strength and energy to do it. It's worth it in the end. That I can tell you.

Linda: Yes. Thanks Bob. And Thanks Debbie. Recovery is hard. And it is worth it.

Bob M: Some audience thank you's:

Monmas: Something I have learned--don't be afraid about how long it will take to recover. Take it one day at a time. There is no schedule to follow on recovery. It will be at your own pace. Thank you Linda and Debbie.

Rod: Thank you for your openness and willingness to use that to be so helpful with your comments. Sometimes the end can be the beginning.

Siteline: Thanks for the insights.

Versus: THANK YOU SO MUCH!

Bob M: Good Night everyone.

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Bob M: Good evening everyone. We are ready to start tonight's conference. I hope everyone had a pleasant holiday. Our first conference of the year, tonight, is "Breaking Free From Your Eating Disorder--Getting the Help You Need". We are always trying to focus on doing positive things and offering things to help with recovery. Our guest is Jonathan Rader, Ph.D. Dr. Rader is the Chief Executive and Clinical Director for Rader Programs, one of the nations leading providers of inpatient, daycare, and outpatient eating disorder services. He has worked in the field of eating disorders for over 17 years. His work has been documented in eating disorder journals. Good evening Dr. Rader and welcome to the Concerned Counseling website. Before we get underway with tonight's topic, could you please tell us a bit more about your expertise and the Rader Centers and where they are located?

Dr. Rader: We, at Rader Programs have been treating anorexia, bulimia, and compulsive overeating since 1979 and we currently have two locations, one in Tulsa, Oklahoma and one in Los Angeles, California.

Bob M: I'm going to assume that most people here know if they, or someone they know, has an eating disorder. The question is: how do you know that it's really time to get professional help?

Dr. Rader: That is a good question, Bob. A person really needs to look at the amount of dysfunction the eating disorder has caused in all areas of their life; physical, emotional, social, family, and work.

Bob M: One of the big questions we always get is what kind of treatment should you get. Outpatient, inpatient, or just see a therapist once a week or so. Can you explain the criteria one should use to evaluate that issue?

Dr. Rader: Unfortunately there is not a simple answer to that question. We, at Rader Programs, try to treat the patient with the least restrictive environment; but since eating disorders affect all aspects of an individual's life, the most effective treatments have included the use of a multi-disciplinary treatment team. It is important not to ignore the nutritional, exercise, and physical components of the eating disorder.

Bob M: If you are just joining us, welcome. Our guest is Dr. Jonathan Rader, of the Rader Programs. Our topic is: "Breaking Free From Your Eating Disorder--Getting the Help You Need". Here are a few audience questions Dr. Rader:

Shanna: After you have recovered (symptom free) and you still get the feelings to purge, what are some good ways to get past the feelings?

Dr. Rader: At Rader, we look at eating disorders as an ongoing recovery process . Even though you may no longer be in the throes of your disordered eating, feelings may still come up around eating disorder issues. It is okay to have these feelings and to realize that you did not develop your eating disorder overnight nor will all of the feelings disappear overnight.

Bob M: Is it possible to prevent a relapse, and if so, how?

Dr. Rader: Sometimes relapse can be part of eating disorder recovery. We often say it is important to never be too hungry, angry, lonely, or tired. ( HALT).

Winkerbean: What do you recommend for getting through denial, even after having completed outpatient treatment and still being in denial?

Dr. Rader: We use a process called our First Step. It gives an individual the opportunity to look how their life has become unmanageable because of the eating disorder. The person writes down the first remembrances of their eating disorder up until the present time. Family members and friends are also good at pointing out the dysfunction the eating disorder has caused.

Bob M: I know that various treatment centers have their own focus, or way to recovery. Some offer 12 step programs, others behavioral therapy. How does one determine what would be best for them?

Dr. Rader: According to the APA (American Psychological Association), eating disorder treatment programs must have a multi-disciplinary treatment team and process. It must be able to address the medical, psychological, nutritional, and behavioral issues associated with having an eating disorder. I would recommend not only going with a treatment center that you feel comfortable with, but one that also has a medical doctor, registered dietician, family counselors, and individual counselors.

Bob M: Here are some more audience questions:

Katiebee: My daughter is bulimic. Now she is gaining so much weight. I'm worried.

Bob M: So what's a parent to do in this situation? and really any situation where they are concerned about their child or relative, but that person is in denial or doesn't want help?

Dr. Rader: Weight fluctuations are common in eating disorders. It is important for both of you to get in contact with an eating disorder professional as eating disorders are a family disorder.

Bob M: One of the most difficult things though is actually getting the person to accept the idea of treatment. Can you give us some insights on how to accomplish that?

Dr. Rader: It is important for the person to look at how the eating disorder has affected their life. If they can look at how their lives could possibly improve for the better, they may be willing to accept the idea of intervention.

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Marion: Dr. Radar, what about a situation where the ED sufferer is ready and willing to begin her recovery process, but the parents are in denial, and basically tell her to smarten up and 'be normal'?

Dr. Rader: If it's possible to get the parents alone without the child, you may be able to deal with their feelings of being responsible for the eating disorder, which they are not. Parents who are reticent to let their children seek treatment often feel guilty and responsible for their child's eating disorder.

Bob M: Our guest is Dr. Rader. We are talking about recovering from your eating disorder. Dr. Rader is a psychologist and CEO of the Rader Programs (Treatment Centers) in California and Oklahoma. They offer in-patient and out- patient treatment. 

Angel: I'm 31 years old have had anorexia for 16 years. Is there hope for me? Can I overcome this or will I have this the rest of my life?

Dr. Rader: Yes, there is definitely hope for you. If you want recovery it is there for the taking. We have seen many patients in your situation come to the other side of this devastating disorder. It won't be easy, but if you want to overcome your eating disorder, you'll need professional help and support.

Bob M: Which eating disorder is easier to overcome, anorexia or bulimia? and why?

Dr. Rader: Both are extremely difficult. People used to believe that anorexia and bulimia were mutually exclusive disorders. It is now known that many individuals bounce between both disorders. Neither should be taken lightly as eating disorders have the highest death rate among psychiatric disorders with 10% succumbing to death.

Bob M: When someone comes to the Rader Programs, how long does treatment usually last, in general, and what is the regimen like?

Dr. Rader: The length of stay varies for all patients, but average length of stay is between 2 and 4 weeks. The regimen is highly structured with treatment beginning early in the morning and lasting until bedtime. Throughout the day our individual and group settings address the eating disorder and the many issues that accompany it.

Bob M: Here's why I ask. Is 2-4 weeks really a realistic time period when it comes to recovery? Can someone truly recover in that short period of time, even if they work hard at it?

Dr. Rader: No. We are not looking at having a person totally recover from their eating disorder in this short time period. What we are doing is addressing the main issues so that the individual can continue their recovery with an individual therapist or support group.

Bob M: Thank you for clarifying that because I think many people believe, you check into the eating disorder treatment center, you should be "cured", and then they have a relapse. But what you are saying is the treatment center is more like "intervention"...trying to break the habits and form new ones. But you still need intensive treatment to continue with your recovery. Am I correct in that?

Dr. Rader: Absolutely correct, Bob. I wish there was a magic cure. Unfortunately, it takes a lot of hard work to overcome an eating disorder, but we have seen thousands of patients truly gain their lives back.

Naia: I've been in recovery and therapy for nearly a year, but whenever I'm under a lot of stress (like during the recent holidays), I return to starving and excessive exercise. How can I stop those old habits?

Dr. Rader: One of the techniques our patients use during the holidays is obtaining a food buddy. This person is someone you can commit your food to prior to a difficult meal such as a family or work party. This person is also available to discuss how the meal or difficult event went. If you still have difficulty I would suggest contacting your therapist.

elizabethsm: What do you do if there isn't anyone on your area qualified to treat eating disorders and you can't afford to go somewhere?

Dr. Rader: We at Rader Programs truly believe in the effectiveness of support groups such as Overeaters Anonymous and ANAD. You can find a listing of OA and ANAD groups by finding their website-we have links to both on our website.

rndochka: I have EXTREME difficulty swallowing. It doesn't matter if it's water or popcorn. I constantly feel like I'm choking. Is this a symptom of anorexia or sexual abuse or both and what can I do about it? I'm getting dehydrated because of this problem.

Dr. Rader: It is important to first rule out a physical problem by seeing your general practitioner. If it is determined that there is nothing physically wrong, it would be recommended to explore these issues with a therapist. Many of our patients have this same symptom as a result of anxiety, sexual abuse or their eating disorder.

Bob M: I also want to explore another eating disorder that people usually don't put in that category of "eating disorders" and that's compulsive overeating. Do you have a program for that? There are many people who come to the site and want help, but don't know where to turn (after failing at many different diet programs).

Dr. Rader: Yes. We treat compulsive overeating just like any other eating disorder. It does not matter whether you are underweight or overweight. If food is being used for something other than nourishment, the person may have an eating disorder.

Debzonfire: If eating disorders patients are so "competitive" in their bid to lose weight, competitive with each other that is, why would you put them all together in a support group?

Dr. Rader: We have found that the power of a group of individuals exploring their dysfunction together can be more effective than in individual therapy. People who are exploring similar issues can often see parts of themselves in others. It is true that there is competition among some patients, but we use this as an issue to address as the same competitive issues happen every day outside of the treatment setting.

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love those carbs: Are there any support groups for families and husbands of someone who has a eating disorder?

Dr. Rader: Yes. Some communities are lucky enough to have co-compulsive  Overeaters Anonymous groups. Many universities also have support groups for family members.

Tiffanie: I am wanting to become pregnant in the near future, but my gyn says I have an infertility problem we need to work with. Can this be caused by my bulimia?

Dr. Rader: The practice of eating disorders can be a cause of infertility. I would recommend always checking with your ob/gyn.

baby butterfly wings: I don't understand how it is possible to have anorexia and bulimia at the same time. Is that just a false piece of information?

Dr. Rader: People usually do not have both eating disorders at the same time although you can have anorexia with bulimic symptoms or vice versa. Also, it is common for an individual to start off with anorexia and then move into bulimia as they may be eating just to satisfy their family members and then purge secretly.

mleland: I was in a program for 7 weeks and wanted to get better, but relapsed immediately. How does your program work faster or differently?

Dr. Rader: Unfortunately, I do not know the specifics of the program you were in. I can only tell you that our multi-disciplinary approach will work if you are willing to put the effort in. Just because you relapsed does not mean that you did not benefit from the treatment. It is important that you work the tools that were given to you. BREAK

Bob M: What about medications Dr. Rader? Is there anything out there that can significantly help someone with an eating disorder?

Dr. Rader: Currently the most commonly used medications for eating disorders are Tofranil, Norpramin, and Prozac. These medications affect the release and uptake of the neurotransmitter serotonin. Some physicians are using naltrexone, a medication that blocks the natural opiods. But medication alone is not as effective without therapy.

Allison: How do eating disorders get worse over time? It seems like somehow they start off as no big deal.

Dr. Rader: Eating disorders are progressive disorders. It may seem as though they are something you can control when you first start practicing them. But like alcoholism, they can become addictive and produce a devastating cycle.

Dr. Rader: I know it's getting late. I want to thank Dr. Rader for being here tonight and for everyone in the audience who attended and those who submitted questions.

Dr. Rader: Thank you for having me as a guest speaker tonight.

Bob M: Good Night everyone.

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Bob M: Good Evening and welcome everyone. Our topic tonight is "Defeating Your Eating Disorder". Our guest is Dr. Ira Sacker. Dr. Sacker has a "bit" :) of knowledge on the subject of eating disorders. He's the director and founder of HEED--Helping to End Eating Disorders at the Brookdale University and Hospital Medical Center in New York. He's also the author of the well-known book: Dying to Be Thin: Understanding and Defeating Eating Disorders. And he's written numerous articles on all facets of eating disorders--anorexia, bulimia, and compulsive overeating. I'm Bob McMillan, the moderator for tonight's conference. As we proceed through the conference, we'll not only be talking about how to defeat your eating disorder, but I also want to address some new research reports that came out talking about psychological disorders in relatives of women with eating disorders. I want to welcome Dr. Sacker to the Concerned Counseling Website...and maybe we could start with you telling us a bit more about your expertise in the area of eating disorders.

Dr. Sacker: Thank you, Bob. I have been involved in eating disorders for the past 25 years. During that time, I have treated many individuals with anorexia, bulimia and bulimarexia. We are now seeing an increased incidence of second generation eating disorders.

Bob M: And I want to address that issue later in the conference. So we are on the same track tonight, since we are talking about "defeating your eating disorder", can you define what the word "recovered" means when it comes to the various eating disorders?

Dr. Sacker: Well, this is a difficult issue since we see a lot of recurrence with eating disorders. Recovery generally implies that the individual is at a relatively normal weight for height, has greater than 17% body fat and psychologically is able to more effectively deal with his or her issues.

Bob M: What if you've added weight, but you still have some eating disordered behaviors. Are you still considered recovered? And is "cured" the same as "recovered"? Or is a person with an eating disorder never really "cured"?

Dr. Sacker: Most eating disorder patients still have some eating disordered behaviors, i.e., still concerned with portion size, etc. I would still consider them in recovery.

Bob M: What makes it so difficult to recover from an eating disorder?

Dr. Sacker: Eating disorders are not about food, but about underlying issues of control, low self-esteem, underlying depression, obsessive-compulsive behaviors which are being masked by food.

Bob M: For those of you just joining us, I'm glad you could make it. Our guest is Dr. Ira Sacker, eating disorders treatment expert and author of the book: Dying to Be Thin. We're discussing "defeating your eating disorder". So are you saying that for a person really to get on the road to recovery, they have to deal with the other issues first?

Dr. Sacker: Absolutely . Often the eating disorder acts as a protection from the underlying feelings of being overwhelmed. With anorexia and bulimia, the behaviors of restriction as well as bingeing and vomiting causes a release of endorphins which give the individual a false "high". To treat these disorders one needs to have a treatment team composed of a physician, nutritionist and therapist all well versed in eating disorders.

Bob M: Your book talks about "defeating" your eating disorder. What do you think are the most effective ways of treating an eating disorder and defeating it?

Dr. Sacker: The key is forming a relationship with your client. This involves not only an understanding of the illnesses, but also a sensitivity to the individual and the family.

Bob M: So are you saying there's no "magical" cure, no drug that will do it "once and for all"? That really the key to eating disorders recovery is getting a good therapist who will work with you through your problems?

Dr. Sacker: Cognitive behavioral therapy, oftentimes in conjunction with specific SSRI medications, i.e., Prozac or Paxil etc. has been effective in decreasing the binge-purge cycle. But it is certainly not a magical cure by itself. Finding a good therapist is like going shopping. You must be comfortable with the individual.

Bob M: Here are a couple of audience comments, then onto audience questions:

Horace: I believe that recovery is about healing the eating disordered behaviors plus dealing with the underlying issues. You cannot have one without the other. Recovery is about integrating behavior + emotional healing.

Chelsie: I've been dealing with anorexia for 10 years and my fears just keep winning. HELP!

Dr. Sacker: Chelsie, many of our clients have had anorexia for over 10 years and are presently in recovery. The key here is not to beat yourself up when you have setbacks. It may be a good time to seek out another therapist or eating disorders specialist for a consultation. Sometimes people who have acted as kind and supportive therapists, do not have enough training in eating disorders.

otherpea: I'm on a food plan done by a nutritionist, and have an experienced therapist, and support groups. I would like to know if an ED person with those underlying feelings and emotions that cause the eating disordered behaviors to surface can ever get over or be free from these "horrible" feelings and emotions?

Dr. Sacker: You can certainly get beyond them, but even in recovery eating disorder patients will still compare themselves to other thin i

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Bob M: Are you saying then, that the behaviors and thoughts never really disappear, but in recovery an eating disorder patient learns to control those thoughts and recognize them for what they are?

Dr. Sacker: I could not have said it better myself.

grin: Dr. Sacker, what is the recovery rate based on your practice?

Dr. Sacker: That is always a biased report. We have been very fortunate and have had a very high recovery rate. However, one never knows what happens to those who don't stay with the program. We follow up all our patients for approximately a ten year period of time. The door is always left open so that they can come back to us if things get rough.

Bob M: In your book, Dying to Be Thin, you spoke to many eating disordered people. Some had been suffering for years. Was there something they had in common that made it easier for some to recover vs. the difficulty that many sufferers have in reaching that point?

Dr. Sacker: Those who recovered earlier developed an insight into their underlying problems and felt it safer to move away from the eating disorder. Others were so addicted to the eating disorder behavior that their identity became one and the same.

LMermaid: Is there a difference between recoveries of people who have had eating disordered behaviors and active phases since childhood vs. a person who may have become active with an eating disorder at a later stage in their life?

Dr. Sacker: Individuals who develop eating disorders at a later stage usually have an earlier history which has gone undiagnosed and untreated , therefore many of them have been leading eating disordered lives for many years. The earlier the diagnosis, the younger the age, the better the prognosis.

Marlena: Dr. Sacker, do you find that as a person begins their struggle with recovery, often times the eating disorder is replaced by another "addictive situation", be it replaced by drugs, alcohol, etc.?

Dr. Sacker: Bulimics have a greater tendency for developing other addictive alternatives. The anorexic does not generally develop other addictive disorders.

Bob M: Here's an audience comment on developing other addictions:

Sunflower1: I disagree. I was anorexic for 15 of my 25 years and up until about a year ago, I was a drug addict.

Bry: Is there a method of therapy that has a higher success rate for eating disorders? (therapy for eating disorder)

Dr. Sacker: I have found that interactive therapy seems to work more effectively than traditional psychotherapy.

Bob M: And what specifically is "interactive therapy"?

Dr. Sacker: Interactive therapy is a combination of cognitive behavioral therapy as well as a direct interaction between client and therapist focusing on the positive aspects of the individual rather than the why's.

Bob M: Dr. Sacker's book is entitled Dying to Be Thin. You can click on the link to purchase it. One of the things I wanted to address tonight is the issue of "passing along" your eating disorder to your children. Is that possible? And if so, what can be done about it, even if one hasn't recovered yet?

Dr. Sacker: Recent studies show that it is possible to pass along your eating disorder to your children. Genetic, biochemical and environmental possibilities have been entertained. I am still a believer in the concept of "teacher by example" and we are seeing younger and younger individuals, as young as five or six with eating disorders whose mothers have been undiagnosed and untreated for their own.

Bob M: But what can one do, even if they haven't recovered, to keep their children from developing an eating disorder?

Dr. Sacker: We are beginning prevention aspects to our program. If they don't develop the disorder, it does not have to be treated. Families must be treated as a whole to this end . We are seeing the effects of media and societal pressures, even in the elementary schools where pre-k and kindergarten children are concerned about their bodies and how it compares to others. We are beginning a puppet project in the elementary schools.

Bob M: As I mentioned earlier, Dr. Sacker is the director and founder of HEED--Helping to End Eating Disorders at the Brookdale University and Hospital Medical Center in New York. We'll be giving you some more information on HEED in just a few minutes.

Bob M: A recent study concludes that the relatives of persons with eating disorders appear to be at increased risk of related disorders. It was found that the risk of major depressive disorders, eating disorders, generalized anxiety disorders, and obsessive-compulsive disorders was increased between 2 and 30 times in the family members of women with eating disorders, compared to the risk in relatives of women without the disorders.

Dr. Sacker: That's true, Bob.

Bob M: Authors note that the risks of social phobia and obsessive-compulsive disorders were higher in relatives of anorexics, compared to relatives of other participants, and that the risks of alcohol or drug dependency were higher in relatives of bulimics. To me, that's pretty alarming. As a parent, if I had an eating disorder, I'd want to know specifically what I could do to help my child. What ideas do you have concerning that?

Dr. Sacker: We continue to see this in our own population and have contacted other programs who have likewise reported the same instances. First of all, you must deal with your own disordered eating behavior. Correct the behavior. Children follow by example. We must also learn to accept our children as they are and teach them the same. Parents should seek expert help if they are having difficulty with eating behavior in their child.

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SarahAnne: Does that statement include my younger sisters being more prone to anorexia because I have it?

Dr. Sacker: It may, but not always. Don't feel guilty! Try not to make food an issue in the family.

Hopeful: I've tried both one-on-one therapy and group therapy and did not find that either helped. I am on Paxil which seems to lighten my moods a lot, but I'd like to know if you have any suggestions for people trying to recover on their own.

Dr. Sacker: It's very difficult to heal oneself from the inside. I would recommend locating a new therapist.

Gabrielle: Dr. Sacker, you mentioned medications for bulimia. Do you have any medication suggestions that you feel might work for anorexia?

Dr. Sacker: Many individuals with anorexia have ocd, obsessive-compulsive disorder and therefore medications like Luvox or even Prozac have proven somewhat effective. Also SSRI's are helpful when the underlying disorder is depression.

Bob M: As I mentioned earlier, Dr. Sacker is the founder and director of HEED...Helping to End Eating Disorders, at the Brookdale University Hospital and Medical Center in New York. Dr. Sacker, can you talk a bit about HEED and its purpose?

Dr. Sacker: HEED is a not-for-profit program geared towards the prevention, education, referral, diagnosis and treatment of all eating disorders with the hope of raising enough money to develop HEED HOME, a home for patients to go to in between the hospital and the home or the other way around.

Bob M: That sounds wonderful. And you're having a fundraiser coming up, right?

Dr. Sacker: That's right Bob. It will actually be a great night out at the Woodbury Jewish Center in Long Island. We will have special guests, raffles, auctions and a lot of fun for a great cause. We invite all to call us for further info and join us. You can call at 718-240-6451. It will be on Thursday, November 12 at 7 p.m.

Melbo: Yes, I've been in recovery from bulimia and anorexia for 2 years now and still have a lot of problems with body image. But I can't seem to get help with that. I want to talk to someone about it, but I've never heard of anyone who specializes in body image, at least not here in Nashville, TN. Are there specialists for that and where do you find them?

Dr. Sacker: Many nutritionists and eating disorder specialists are well-informed of body image issues. Call me and I'll try to locate the nearest program for you. By the way, we also have an interactive website that does referrals.

Flyaway: Are eating disorders related to obsessive-compulsive disorder?

Dr. Sacker: Obsessive-compulsive disorders often underlie many forms of eating disorders.

expacobadj: I am definitely OCD and social phobic to the extreme and that is what I hate! How do you know that you are not faking yourself into thinking you are recovered?

Dr. Sacker: Please rephrase the question, Bob?

Bob M: If those with eating disorders have distorted body images, let's assume they can distort other things as well. How can you tell if you've really recovered, rather than fooling yourself into thinking you've recovered?

Dr. Sacker: Part of recovery is in learning to trust your own feelings and become aware of others around you. If you are more accepting of yourself, you will find that you are reaching true recovery.

sandrews68: How have you treated people with severe/long-standing eating disorders? I'm at my wit's end. Please tell me how other severe cases have been overcome.

Dr. Sacker: We have had some success in the treatment of long-term eating disorders. Please call us or contact us at our web page.

sin: With compulsive binge eating, what is it with the human psyche that makes the feeling of relief from the action of food?

Dr. Sacker: It's not only the human psyche, but specific biochemical changes that cause these feelings. More and more we are finding individuals who are chemically imbalanced. Many of these can be treated nutritionally and with specific medications.

Bob M: I have one last question. Can one recover from an eating disorder on their own, without the help of a professional, or is that next to impossible?

Dr. Sacker: Some individuals remove the symptoms of the eating disorder without dealing with the underlying issues. Therefore, years later the eating disorder may surface again or wind up as another form of addictive behavior.

Bob M: Thank you for coming to the site tonight, Dr. Sacker. I appreciate that you stayed late to answer everyone's questions.

Dr. Sacker: Thank you all very much for your interest.

Bob M: Thanks again Dr. Sacker and good night everyone. Don't forget tomorrow night's conference (Wed.) is on ADHD in children--our back to school conference with Dr. David Rabiner.

Bob M: A little audience reaction to the conference follows:

Flyaway: Thank you Bob and Dr. Sacker for your conference.

Alisonmp2: I really liked your book. It helped me when I was going to go inpatient to read the stories that you had in there! THANKS

eLCi25: Thank you, doctor and Bob. This conference has given me some things to think about.

Bob M: Good Night everyone.

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Bob M: Our topic tonight is Eating Disorders Hospitalization. We have two sets of guests, with two different perspectives on it. Our first guests are Rick and Donna Huddleston. They are from South Carolina. They have a 13-year-old daughter named Sarah, who besides having other medical problems, suffers from a severe eating disorder. During a really difficult period for them, they put up a website and told Sarah's story. There were periodic updates on what was happening. I'm going to start by having Rick and Donna tell us a bit about Sarah's health situation and then we'll get into how difficult it was to get her the proper treatment. Good Evening Rick and Donna. Welcome to the Concerned Counseling Website. I know it's been very difficult for you, as well as Sarah, over these last few months. Can you share with us a bit about Sarah's condition and her eating disorder?

Donna Huddleston: Sarah developed an eating disorder at age 12. It started when she went through a huge surge of hormones. She did not want all the changes that were happening i.e.: curves. She started by watching her diet first. Then she found out she had to have emergency surgery for scoliosis (the result of rapid growth + brittle bone disease). She was told she could not exercise for a year. After surgery she started watching her fat intake, which progressed on to no fat, to angry outbursts about food. Ultimately, that resulted in her hospitalization for the rage. They put her on Zyprexa, a new drug at the time. It is now known it should not be given to those with an eating disorder. She flipped into full blown bulimia. She was taking in 6000+ calories a day. The doctors got her off the Zyprexa, and stable for a bit, but then Sarah proceeded back into the bulimia. Finally, she ended up in the hospital again with 2.0 potassium. It was decided by all that residential treatment was needed. We have no programs avail here in South Carolina. She is now in California at the Montecatini Treatment Center.

Bob M: I want to add here, that Sarah was very ill and desperately in need of treatment for her eating disorder. You had a great deal of trouble getting her hospitalized. Please tell us about that. I think it's very important for many people here to realize how badly you wanted to get Sarah help.

Rick Huddleston: Sarah's problems with eating are very complex, as most are, and here in Columbia, the only type of treatment is what we consider "old typical". They are only there to stabilize and release. Even the local "experts" at Charter Rivers Hospital, were unprepared and incapable of helping. They misdiagnosed her, would not listen to us (marking us as problem parents). This was, in part, due to Sarah's behavior. She would never act out anywhere but home and mostly direct her anger at Donna. After 3-4 hospitalizations, we knew we were in trouble, and had to look elsewhere. Typical treatment there was a "forced" meal (sometimes catered by a food preparation service), full of grease, and not very balanced, followed by a forced sitting at the nurses station for 1 to 2 hours. This would be the extent, with the exception of medications, and counseling. But these groups were mostly comprised of kids with serious drug, alcohol, or ones having been raped or abused. Obviously, this was not a good place for a young girl with no self-image and feeling totally out of control of her life.

Bob M: And, so to clarify, she was not at an eating disorders specialty treatment center at this point. Please continue Rick.

Rick Huddleston: True Bob. But in South Carolina, there are NO specialty centers that really understand and can treat ED. We did find the local expert in Charleston. He looked at Sarah, charted her weight, and said "she is ok".

Bob M: I understand. And, as many in previous audiences for our e.d. conferences mention, there are many places across America, in small and midsize towns, that don't have eating disorders treatment centers, or even specialists, for eating disorders. So what did you do Donna?

Donna Huddleston: Most of the residential facilities we found would not admit teens, or only had an out-patient program wherever the facility was located. That would involve us moving, which we could not do. We contacted Remuda Ranch. Our insurance would pay in full, but they wanted $71,000 up-front, in cash, "then the insurance can reimburse you", I was told. We then located a place called Montecatini in Carlsbad CA. It is usually minimum of 8 months+ for residential, in-patient, treatment.

Bob M: I don't want to gloss over this...you got to Remuda and they asked you for $71,000 cash. Were you expecting that? And what did you do?

Donna Huddleston: No! I was NOT expecting that! We had to go through a fine toothed comb investigation of our finances. They knew we could not afford it out-of-pocket. Even with letters to Remuda from the insurance companies, they asked for the money up-front. I asked if everyone paid this way and I was told "Yes". I later found out they are a for-profit facility. I told them I could not do this and then moved on. We had to get Sarah into the right place quickly. At 5'4" she was down to 88 pounds.

Bob M: If you are just joining us, our guests are Rick and Donna Huddleston. We are talking about the ordeal they had to go through to get their now 13.5-year-old daughter, Sarah, proper in-patient treatment for her eating disorder. I'm Bob McMillan, the moderator. Just thought I'd introduce myself because there are some new people in the audience tonight. I want to welcome everyone to our site. I hope you'll get some useful information from tonight's conference.

Rick Huddleston: We did NOT expect to be told to pay up front! Remuda told us to mortgage the house, borrow from relatives, take a loan, drain retirement, etc. All that, even with letters from our insurance stating they would pay.

Donna Huddleston: They also asked for the names, addresses and phone number of relatives so they could check with them about helping with payment.

Rick Huddleston: In all, we spent around 3 months tracking down every lead for long-term residential eating disorders treatment we could find.

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Bob M: As we continue with this story, I want those of you in the audience who are younger and sometimes point out that your parents wouldn't understand or do anything, to listen to this. And I truly believe, while the Huddleston's are wonderful and inspirational people, there are many good parents like them out there. So you left there and went onto California to a small residential treatment facility where Sarah is today. But before you could get her in, what happened?

Rick Huddleston: We had all areas covered except for one. In California, Montecatini falls under the Community Licensing Bureau. We had to get an approval (exception to age) waiver from them. This had been given before, so we did not expect any problems. We had Sarah hospitalized with her potassium down and knew we had to make the trip and take our chances. Once there, we met the "bureaucrat from hell". She thought she knew better than anyone. Although she has no medical training, and no medical knowledge, and never had been exposed to anyone with an eating disorder, she fought us for a week, basing her rejection on the 48 hours program about the little girl with ED.

Donna Huddleston: Also, keep in mind we were already in California at this point, with Sarah.

Rick Huddleston: She sat across the table from Sarah and told her to her face to go home!

Bob M: So you needed to get this special permission from the state of California for her to be treated there because she was a minor and you were from South Carolina. How did you get it?

Donna Huddleston: Just because she was under 16, it did not matter the state of residence. But they had issued this waiver for 5 others under 16 before Sarah.

Rick Huddleston: Being the way we are, we left the meeting, contacted a few internet friends, and within 48 hours had the Governors from California and South Carolina, as well as officials from Washington, pushing to get her in. Also the local NBC affiliate got involved doing interviews and preparing a story for airing. We were in California for 9 days and finally the Governor's office was on the phone to this lady at 4:45 p.m. on Friday "ordering" her to write the waiver. Sarah was now down to 74 pounds and at the point of turning critically ill.

Donna Huddleston: The licensing board gave us the name of the San Luis Del Rey hospital and told us to take her there. We contacted them by phone, just to check their "program" and was told by the director of SLDR to fight for Montecatini. By this time, Sarah's body had begun to turn on itself. Within a few days, she would have to be hospitalized or dead.

Bob M: I spoke with Donna this afternoon. She told me in detail about Sarah's eating disorder, how bad the bulimia had gotten. At one point, Sarah was binge-purging several times a day. Her binges were so strong, Donna and Rick chained the refrigerator closed.

Donna Huddleston: And padlocked the cabinets.

Bob M: In addition, Sarah is a strong-headed young lady and she constantly fought her parents on the treatment issue. What was it like Rick or Donna, when you first got Sarah to the doors of the eating disorders treatment center?

Rick Huddleston: Bob, you have a way of understating the facts:) At the time we left for Montecatini, Sarah had admitted to herself that she had a problem and was ready to start treatment. She asked us for only one thing. The last day in town, she wanted to go to school (the first day in months), so she could tell her friends goodbye, and tell them why she had been out, where she was going, and just how sick she was. Until this time, we had been visited by DJJ (Dept. Juvenile Justice, or Social Services in South Carolina), after being turned in by Sarah for abuse. We had the police at our house 3 times and Sarah was arrested for Criminal Domestic Violence once.

Donna Huddleston: It was the week of National Eating Disorders Awareness Week when Sarah went to school that day. I had begged the schools here to do something that week and they refused. So Sarah, herself, spent the day telling her friends goodbye and explaining what an eating disorder was.

Rick Huddleston: It was a long and very destructive year, not just for Sarah, and her health, but the emotional and financial toll it took on the entire family.

Bob M: She's been in now for about 11 weeks. What's it been like? Do you hear from her? And by the way, just so everyone knows, this program Sarah is in runs about 9-12 months.

Donna Huddleston: She is allowed to call home every Wed and Sun.

Rick Huddleston: The program at Montecatini is very intense and busy. We hear from her 2 times a week and travel to California for family counseling every 6 weeks and stay a week each time. Her day is filled with exercise, sessions (both group and individual), shopping, cooking, and school. The girls there are completely self sufficient, having to plan everything themselves (of course, under close scrutiny of the staff).

Donna Huddleston: The first 6 weeks, she would not talk in group or to anyone about her feelings. When we got there after the first 6 weeks, we got her to open up and she has been working on her issues now. I did get her call Wed. night though and she was back to the "I want to come home and get back to my "normal" weight" stuff. She weighs ~100 pounds now, with a goal weight of 110. That terrifies her. We got her out of her panic today with a potential compromise. She told the Dr. ALL of her friends are thinner than her. So we are off on a round to do a photo album of her friends now. We will take it to her in two weeks. And if it is okay with the parents, they will tell us their kids' weights. Most are not as thin as Sarah perceives. The Dr. hopes this will help allay some of her fears.

Bob M: So, 6 weeks into the program and she is still struggling. That's how difficult it can be sometimes to tangle with an eating disorder. I also want to mention, that many Eating Disorders Treatment Centers around the country, DO NOT require cash up front if you have insurance coverage. Here are some audience questions:

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BloomBiz: What made her finally WANT treatment?

Donna Huddleston: It came down to going into treatment or the state hospital. Her moods were becoming more violent, and that was not Sarah's real personality. Also, a friend from the net with a long history of struggling through her eating disorder talked to Sarah, encouraging her to get help.

Rick Huddleston: Bob, we did not mean to say all eating disorders treatment centers ask for cash up front. Remuda is a "highly" advertised facility, which I believe leads parent into a false sense of help.

Bob M: I understand your position. I just wanted to clarify that for the audience because I didn't want anyone to think that if they didn't have $71,000, they couldn't get treatment.

HelenSMH: They will not let her leave right? She has to stay for the entire 9 to 12 mo. right?

Rick Huddleston: As a minor, yes, she has to stay, or "run away". This is NOT a lockdown facility, and they keep the girls in public a lot. It is the staff and Sarah who must decide when she is ready to leave, and Sarah (when not engrossed in her disease) agrees.

Donna Huddleston: Also to clarify, all other places we called would accept insurance. The problem was that the other residential programs were of short duration, and we knew Sarah needed a longer, extended stay to deal with her problem.

Bob M: The treatment facility though has a policy about what happens if you go back to your old eating disorder habits. Can you explain that, Donna?

Donna Huddleston: If Sarah skips one meal, she is "out" technically. They are really strict about that. We managed to get her to agree to eat after our conversation today. She was on the verge of refusing. We have had to go to "tough love" at this point. Sarah knows if she does not cooperate she will be escorted home by State Police Marshals and taken to the state hospital here. It is extremely difficult being that "hard", but if we give in, I know we will lose her.

Coral: Do you think that being there for so many months, in the long run, is going to be more help than a shorter program?

Donna Huddleston: Sarah is very stubborn and I hope someday she uses it to her benefit. We knew a 1-2 month program would not work, and we are seeing that already as she is in week 11.

Bob M: And she is still being combative and wanting to get out of there at times. And remember, we are also dealing with a 13-year-old, not an adult who can rationally think things through based on experience.

Donna Huddleston: She is not combative physically with them, just mentally, stating at times she is not going to eat.

Rick Huddleston: It is not only the age, but Sarah has been through more than most adults...medically and emotionally. Her natural father left many scars which are taking their toll as well. If she can get through this in 3 months, or if it takes 3 years, all we want is for her to get well.

Bob M: Here are a couple of audience comments, then more questions:

HelenSMH: Oh god. I've also been to the state hospital in Columbia, South Carolina. I wish she could know that's not a place she wants to be. I was only there for three days. That's the minimum stay. It was awful.

Jordyn: Remuda looks at each case individually and does financial interviews with each case. How did you start your search for a treatment center?

Donna Huddleston: You are right Helen! Right now she is in a plush, beautiful house, on a golf course, in a regular bedroom with a roommate.

Rick Huddleston: We started by searching the web. We called and interviewed many facilities. We called the National Eating Disorders Organization, and also contacted our internet friends who are recovering for their help also. In Columbia, the doctors and hospitals were of no help. We were left to our own devices. Also, my insurance company did a lot of research for us as well.

Gloomy: I don't know if I can ask this, but what started her eating disorder?

Donna Huddleston: Sarah feels abandonment with her natural father. She is now back in touch, but it was a bit too late. There was no other kind of physical abuse. He was just never a "father" to her. Rick has adopted Sarah since we married.

Rick Huddleston: Briefly, problems with her biological father leaving her with a feeling of abandonment, a divorce, a new marriage, a move, medical problems, which together gave her a sense of total loss of control.

Bob M: Well, I have to say the two of you are wonderful parents. I know this must be exhausting, physically and emotionally for you. But you have done everything possible and a whole lot more. By the way, is your insurance covering the whole bill, or are you having to pay out of pocket now. And what do you think the bill will come to when the 9-12 months is over?

Rick Huddleston: Our insurance is paying the bill at Montecatini (which is about 20% the cost of normal hospitalization), but....does anyone have a lot of frequent flyer miles they would like to donate? :)

Donna Huddleston: By the way, we have 4 other kids that have survived all this. We constantly strive to keep communication open, as all of them are feeling the loss of our attention for the last few years.

Rick Huddleston: The stay alone is approximately $20,000 per month, plus our expenses for travel, meals, lodging. I haven't totaled it yet, but I would estimate out-of-pocket will be around $30K. To put that in context. Sarah went thru $12,000 in groceries in less than a year, $4000 in clothing, and several thousand in destruction of property.

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Bob M: For those of you just coming in, we mentioned earlier that Sarah was manic binge-purging to the extent her parents had to chain the refrigerator closed and lock the cabinets. Again, thank you for being here tonight, for being an inspiration to many. We all hope Sarah is able to recover and move on in her life.

Rick Huddleston: Manic binge-purge. I haven't thought of it quite that way, but it seems appropriate.

Donna Huddleston: All of the girls in program ( I say girls, but as of our last trip ranged from Sarah's age to 33, average age 20) told us how lucky we were to get her into treatment early. I just pray it works.

Rick Huddleston: I just hope that others can be helped. There is so little information on the parents side of this, and what the toll on the family is. Perhaps a topic for a future session?

Bob M: I think that's an excellent idea Rick and I plan to do that in the near future. Thanks again for coming.

Bob M: Before I move on, I also want to mention, that Rick and Donna said they were thankful that Sarah was able to get treatment relatively early on. That she didn't suffer with her eating disorder for years before getting treatment. That is so critical. If you've been to our other eating disorders conferences, you know our expert guests, like Dr. Harry Brandt, from the St. Joseph's Center for Eating Disorders, always stress how much easier and more effective the treatment is when you get it early on.

Rick Huddleston: One final comment from me. It is imperative that the patient admits and seeks eating disorders treatment. As with all addictions, if Sarah did not recognize it, there is no way she could be treated by anyone.

Bob M: We have a second guest coming, so please give me one minute to take a break. Our next guest, Diana, has been out of hospitalization and free from her eating disorder for 3 years. She'll be detailing her experiences and taking your questions in a moment.

Bob M: Our next guest is Diana. Diana is 24. She suffered from anorexia, then with bulimia for nearly 6 years, before checking into a residential treatment facility as a last-ditch effort to deal with her eating disorder. When she came out 8 weeks later, it was the start of a new life for her. Good evening Diana and welcome to the Concerned Counseling website.

DianaK: Hi Bob. Thanks for having me. I was here when Rick and Donna were talking. What amazing people! But you made a good point Bob. I think many parents would do what they did for their children. I remember when I was 16 dealing with my situation, I was afraid to tell my parents. Afraid they would be angry, I would be punished in some way, or rejected by them. And I speak with many kids today and I tell them that's because you are angry at yourself for having the eating disorder and you project that your parents will be angry too. In most instances, parents care about their children and will do anything they reasonably, and even beyond reason, that they can do to help. It is very painful for them too.

Bob M: Please tell us very briefly what your condition was like before you checked into the treatment center.

DianaK: I was in very bad shape. I had been a restrictive anorexic for 2 years, before moving onto bulimia, and then thinking, like most of us do, that I could control it. I soon found that I had both and was completely out of control. I know everyone in the audience can't see me in person, so I'm going to mention that I'm 5'-6" and now 130 pounds. I was all the way down to 87 pounds. If that tells you anything.

Bob M: What was it like the first day you went through the doors at the treatment center?

DianaK: I was scared out of my mind. I didn't know what to expect. I was 20 years old. My parents forced me in. I didn't want to be there, but I knew deep inside I had to be. There was a lot of paperwork to fill out. Fortunately, my parents had insurance. Most of the $45,000+ was covered. I think my parents paid about $5,000 from their own pockets. When you get there, it's different from what you might imagine. It was a very nice place. Clean, very residential, like home. I sort of imagined the old movies, where they lock you up inside with the "crazies" and you never get out.

Bob M: Did you start therapy right away?(therapy for eating disorders)

DianaK: I guess you can call it that. The dr. and nurses come out to greet you and then there's that scary moment where you say goodbye to your parents and they begin taking you back into the hospital wing. You just want to grab on and say, "don't leave me here". I met my roommate and like where Sarah is, they had a rule. If you don't eat, you don't stay. So for the first night, I ate very little from my plate. But at least I ate.

Bob M: What was the most helpful part of being in-patient vs. out-patient...seeing a therapist at his/her office.

DianaK: Let me tell you this, and everyone who has an eating disorder knows this: it's like heroin, you will do anything to continue the eating disorder. You will lie to everyone. Tell them whatever they want to hear. I found myself at my worst point, fighting for my anorexia and bulimia. Can you imagine that?! I wanted it so bad, I fought for it. Being inside the treatment center, they were very strict and constantly watched over me. But that's what I needed to break my habit. And they also gave me constant support throughout the day. There were private therapy sessions and group sessions and meetings with the nutritionist and my therapist. So, I was kept pretty busy.

Bob M: Here are a couple of audience questions Diana:

Trina: Huh? So that was helpful- lying in therapy was helpful?

DianaK: Good question Trina. No. It was not helpful. I was only hurting and fooling myself. I guess the point I was trying to get across, is that for some of us out-patient is not enough. If your eating disorder has grabbed a hold of your life and visiting a therapist one or two days a week isn't enough, then you need in-patient treatment.

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Monica: What made you stay and eat instead of not eating and running away?

DianaK: When I first got in, the very first days, there were times when I didn't want to eat, but remembered the policy. It literally made me tremble. Also, having others who were a little further along in the treatment and my therapists there along side me, really helped. I knew this was going to be my last chance. And it took a lot of willpower sometimes to force food down me and then not throw it up again. The other thing was, I was physically ill from my eating disorder and I kept telling myself you have to beat it.

Maigen: I don't think that I'm quite ready to get better yet. How do you know when its time for a treatment center or if there really is any reason for one? I still feel like I can control this most days. Is it when there are more bad days than good or what?

DianaK: That's a difficult question Maigen. For me, I knew going to the therapist's office wasn't helping me. I had tried very hard stopping several times over a 6 year span, but couldn't. I would stop for a few days, my longest was 9 days, then start right back up. Also Maigen, I hope you don't have to learn this the hard way, you never really control your eating disorder. That's your mind fooling you. It always controls you. It's just at the beginning, you think it doesn't. As time moves on, it takes a firmer control.

Shelby: I guess I am confused, but I thought that you are never FREE from the eating disorder....you just learn how to accept yourself. Am I not right?

DianaK: I think you are right Shelby. I think once it gets to the point where I was, there is always a temptation to go back--especially if I get really stressed out or depressed. That's one of the things I learned in therapy. If you know what's going to kick you back into your old habits, you have to look at yourself and your situation and say I can't do that. This is not good for me.

Bob M: What was the most important thing(s) you learned while you were in therapy, in-patient?

DianaK: I learned about myself. Ever since I was very young, I was shy. I always let people boss me around, didn't want to hurt anybody, and felt very intimidated by others. Because of that, I kept all my feelings inside. When you do that to an extreme, your body breaks. I've learned how to care for myself, that I matter. That my feelings and thoughts matter. Also, that if I don't express myself, how can anyone help me or communicate with me, or know what I am thinking. So to sum it up, I learned how to cope better and deal with life better.

Bob M: We are talking with Diana...24 years old now. She suffered for 6 years with anorexia, then bulimia, and a combination of both illnesses. Diana finally went in-patient as a last ditch effort to save herself...and was there for nearly 2 months. Now, it's been 3 years since she came out. When you finished with the in-patient program, how did you feel on that last day as you walked out the door?

DianaK: That's not an easy question. Really, and I'm starting to tear remembering this, I was afraid then too. I remember thinking I can't leave these people, my entire support system, and make it on my own. My first reaction was to think of going back to my old friend--bulimia. The therapist had warned my parents about this. Apparently, it's common for many people with eating disorders. My parents took a month off from work, first my mom for 2 weeks, then my dad. They watched over me day and night. I had therapy with my regular therapist in his office 3 days a week in the beginning. And I joined a very small support group, there were 3 of us in the entire city apparently who had an e.d., and we got together 3 days a week and talked and supported each other. I can't tell you how important having support and people who care about you, around you, really is.

Marti1: Diana, do you still go to an outpatient therapist and what have you learned in terms of relapse prevention?

Bob M: Also, if you are interested in getting in or out of patient treatment at the St. Joseph's Center for Eating Disorders, you can fill out the form on the website and they will contact you and answer all your questions. It is one of the top eating disorders treatment programs in the country. They are located near Baltimore, Md.

DianaK: Yes, I still go even though it's been 3 years since I've been out of the hospital. I go about 2 times a month. That's not just for my eating disorder, but to also deal with my other issues and just to kind of keep me grounded. It helps keep things from building up. As far as relapses, like George Washington said, I cannot tell a lie. I relapsed once, about 4 months after I left the hospital, for a period of about 3 days. I worked up the courage to tell my therapist and I got through it with the help of her and my parents and the others in my support group. What I've learned Trina is that you have to recognize the signs of a relapse and what will lead you back down that path. For instance, if I get into a relationship with someone, and it's not right, I can't continually struggle with it. Or, I can't let work stress me out too much. I have a lot of responsibility at my job. However, I have to say to myself, if I don't get any sleep and I start getting angry or depressed, I'm right back where I started. So you have to be aware of what your mind and body can cope with and not go beyond those limits. The second thing is: if you have a relapse, the important thing to recognize is that you don't have to continue with the behavior. Do something about it right away. And forgive yourself, for you are only human.

Bob M: Here's an audience comment:

JoO: Congratulations Diana K...you sound like you have come a long way and faced up to many of your 'ghosts'. I to have an eating disorder -- different than yours -- but the emotional stuff -- not feeling good enough to say no, and keeping things inside are the same and destroy both body and mind. I admire you very much...keep on fighting your fight -- you're winning!!

Stacy: How do you find a good treatment program/hospital?

Bob M: That's an excellent question. I would talk with your therapists. I would call around to the various eating disorders treatment centers and see what they have to offer. And then I'd talk with other former patients and see what they have to say. They have a national reputation. Several people from our site have gone there and said it's been a wonderful program that has really helped them. If you are interested, visit St. Joseph's link for more info. Once you get to the St. Joseph's page, there's a form to fill out for more info.

Bob M: I just noticed it's nearly 10:30 central, 11:30 eastern. We've been going for 2.5. hours. I want to thank you for coming Diana. The insights you offered are valuable. I think it also let's everyone know that it's alright to be scared of the unknown, what treatment will mean and what's ahead in life.

DianaK: And the other part of it is Bob, you have to fight for yourself. You can't sit around and say this will never happen to me because as time goes on, the eating disorder becomes stronger and life becomes a lot rougher. If there is just one message I could bring tonight it would be: TAKE A CHANCE on yourself. Give yourself the opportunity to work through your eating disorder and do it with a PROFESSIONAL. I know it's tough. I've been there. But it's worth it. Trust me. If you've been to hell, anything else is like being in heaven. Good night everyone and thanks again for having me.

Bob M: I hope tonight's conference was helpful to everyone and there was some good information and good karma you can carry with you.

Bob M: Good Night everyone.

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Bob M: Good evening everyone. I want to welcome everybody here tonight for our Eating Disorders Recovery Conference. Everyday, I get emails from those of you with eating disorders talking about how difficult it is to recover from them. You talk about trying, you talk about getting therapy and relapsing and I want you to know that is not that unusual. Recovering from eating disorders can be a long, difficult and trying process. Our guest tonight is one of the top researchers of eating disorders in the country and we'll be discussing why it's so hard and what you need to know to make your recovery longer lasting and more effective. Our guest is Dr. David Garner, Ph.D. Dr. Garner is the Director of the Toledo Center for Eating Disorders. He has published over 140 scientific articles and book chapters and has co-authored or co-edited 6 books on eating disorders. He is a Founding Member of the Academy for Eating Disorders, a scientific consultant for the National Screening Program for Eating Disorders and a member of the Editorial Board of the International Journal of Eating Disorders. Good evening Dr. Garner and welcome to the Concerned Counseling website. I'd like to start with the question: Why is it so difficult for people with eating disorders to make a full and lasting recovery?

Dr. Garner: Thank you for the introduction. This is a difficult question since there are many reasons for failure to recover; however, most significant is the conflict about weight and weight gain.

Bob M: And what is that conflict?

Dr. Garner: Most people with eating disorders suffer from the "anorexic wish"- the wish to recover but not gain weight. This leads to continued attempts to suppress body weight which leads to increased urges to eat. The key to breaking the cycle is becoming a strong "anti-dieter" - a real problem for those who fear weight gain.

Bob M: Before we get into how to accomplish that, I want to also have you touch on the other reasons for failure to recover.

Dr. Garner: Sometimes the eating disorder is a comment on dysfunctional family international patterns and as long as the patterns continue to exist, recovery is difficult. For instance, the problems in recovery may relate to a trauma, such as sexual abuse, and until this issue is dealt with, recovery is impeded.

Bob M: So is that one of the reasons for failure to recover from an eating disorder...that the issues that led up to it haven't been dealt with completely?

Dr. Garner: That is correct. Another one is that the simple wish to maintain a low weight is in conflict with the biological realities related to the person's set point for body weight and this is simply not accepted and the person continues to diet. This may seem like a straight forward issue, but for women in our society, it is very difficult to accept a body weight higher than one would like.

Bob M: Is it possible then to effectively work through your eating disorder while at the same time dealing with the abuse, or other issues, that may have lead up to it? Or to be really effective, should one work through the other issues before tackling the eating disorder?

Dr. Garner: The order of dealing with the issues varies. Usually, one needs to work on both at the same time. In all cases, it is impossible to make headway on the psychological front while continuing to engage in symptoms. Bingeing and vomiting b/v and strict dieting alter your perceptions so much that it is impossible to work on other issues.

Bob M: At the beginning of the conference, I mentioned that those who have relapses along the way, should not feel alone. What does the research say about the number of people who try and recover and have a relapse...and what are the average number of relapses a person experiences?

Dr. Garner: The percent of people with bulimia who recover at a 7 year follow-up is about 70% with another 15% making significant progress. With anorexia nervosa (AN), there is less research and the treatment phase is longer, but 60-70% of patients recover with treatment from a high quality eating disorders treatment facility. Many patients recover after quite a number of relapses.

Bob M: What is the best form of treatment when it comes to making a significant or lasting recovery?

Dr. Garner: The best studied treatment for both Anorexia and Bulimia is cognitive behavioral treatment (talk and behavioral modification therapy). However, for patients under 18, family therapy must be part of whatever treatment is offered.

Bob M: We get many questions here Dr. Garner from folks who want to know, is hospitalization the most effective way to deal with an eating disorder, followed by intensive outpatient therapy or can you just get therapy on a weekly basis?

Dr. Garner: I do not think that hospitalization is necessary or desirable for most patients- intensive outpatient treatment or day hospitalization has replaced inpatient treatment for the most part. Most bulimic patients benefit from outpatient therapy and severe eating disorders usually require something more than weekly, outpatient therapy.

Bob M: Here are some audience questions:

Rhys: How does one become a strong anti-dieter and not gain weight? It seems like an oxymoron.

Dr. Garner: It is, that is why most people decide on some level to opt for trying to continue to suppress their weight. Modest weight gain may occur even in treatment for bulimia.

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Peppa: What if you really have no other issues and the eating disorder is just in you? Do you think some people may be just born with it and that it can't be cured?

Dr. Garner: I do not believe that. Most people with eating disorders can do very well with treatment. There is little evidence that it can't be cured, if you are willing to follow the advice provided in quality treatment.

Bob M: This is the second time you have used the term "quality treatment". What does that mean exactly?

Dr. Garner: It means treatment that emphasizes both the nutritional rehabilitation as well as dealing with psychological issues. This does not mean, encouraging patients to restrict their food intake to low levels of calories (e.g. 1500) or having them avoid sugars or flour or assuming that their eating disorder is an "addiction".

livesintruth: Do you think that family therapy should be part of the eating disorder recovery process for just those under 18? What do you recommend for those 19-25 year olds who are working through the developmental issues of separating from their parents? What is the best way to help parents understand what is happening? Often the person with the disorder is stuck having to tell their family alone. So how do they go about telling them in order that they can believe her and support her?

Dr. Garner: I agree that family therapy should not be limited to those below 18 yrs- it is just that it is mandatory for those who are living at home or who are financially dependent of their family. Family therapy for those 19-25 can be very helpful.

Donnna: Dr. Garner has touched on an area that I am dealing with now. I have uncovered some severe trauma in my childhood years well into my teens. Could this be the reason I have been dealing with this eating disorder for 26 years? Although I have been in a recovery program since April, I feel like this will never end. It's almost as if it has gotten worse than better. Why is that?

Dr. Garner: Often an eating disorder gets worse when the traumatic issues are uncovered; however, this should subside soon. Treatment should assist you in identifying the issues and then, move beyond them.

Shelby: What if your parents pretend as if everything is fine...they don't seem to care whether you skip meals or not?

Bob M: While Dr. Garner is answering that, I want to mention that Shelby's situation apparently isn't unusual. I get about a dozen emails a week from teens asking what to do because their parents don't believe them, even though the person tells them they've got an eating problem.

Dr. Garner: Then there is something wrong with your parents. Would they do the same thing if you were taking drugs, engaging in other self-harm?? Why are they appearing to be so unconcerned? What do they tell you?

Bob M: Let's take it at face value, Dr. Garner, that the parents are in denial. What is a teenage child to do then to get help?

Dr. Garner: Unfortunately, parents can be inept and it is unfortunate that you are suffering. It is possible to consult school counselors or sometimes, even if parents are in denial, they will agree to allow their teenager seek treatment. Don't let you parents' difficulties discourage you from seeking treatment.

JerrysGrlK: What about people over 25 with a eating disorder? How do you overcome the fear and take the first step to get help?

Dr. Garner: Knowing that eating disorders can be cured is reassuring. You are not alone. A phone call to an experienced therapist, just to ask about what treatment involves, is the first step.

twinkle: We are dealing with Dissociative Identity Disorder/Multiple Personality Disorder and was wondering do you have any advice on how to approach the eating disorder while dealing with so many other issues or should we just wait until we have dealt with the other related issues?

Dr. Garner: As I said earlier, it is impossible for you to make headway with the personality disorder or other significant problems as long as you are bingeing or vomiting or starving. Some people find that their so-called personality disorder goes away once they stop the aforementioned symptoms. So, tackle the eating disorder and see what is left.

Bob M: Here are some audience comments to Shelby's earlier statement about her difficulty in getting her parents to help her:

pumpkin: But what happens if even the counselor can't get through to a parent. I know that happened to me and I felt as though maybe there really wasn't anything wrong with me and I got worse.

livesintruth: I'm sorry, but it just isn't that easy Dr. Garner. I personally have experienced that naivety of parents with children who have eating disorders and other mental health problems. There are some parents out there unfortunately who do not let their children get help. They don't encourage them. The parent-child bond is so strong, usually stronger than the bond between the individual and the eating disorder, that individuals will begin to believe their parents' denial.

HelenSMH: Some parents think that it's just phase. How does one make the parent understand that it's not "just a phase"?

Bob M: I think there's only a limit as to what one can do when they are underage. My suggestion would be to speak with a school counselor, someone associated with your church or synagogue, call your family doctor. See if these people will call your parents and try and make an impact. Dr. Garner just sent me a great comment: "How do we make parents competent?" That's for another conference. Is there is significant difference in the way anorexia and bulimia are treated, Dr. Garner?

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Dr. Garner: I agree, I think that there are people out there whose interest is in helping children, even if parents won't. (to earlier comment). Now I will tackle your question. Anorexia and bulimia nervosa share many features in common, so it is not surprising that approaches to therapy for both disorders overlap to a significant degree. Common approaches are recommended for both disorders to address characteristic attitudes about weight and shape. Education about regular eating patterns, body weight regulation, starvation symptoms, vomiting and laxative abuse, is a strategic element in the treatment of both disorders. Finally, similar behavioral methods are also required, particularly for the binge eating/purging subgroup of anorexia nervosa patients. Nevertheless, there are differences in the treatment recommendations made for these two eating disorders. This may partially reflect differences in the personalities, background and training of the main contributors to the literature for these two eating disorders. However, key distinctions can be made between these disorders based on motivation for treatment and weight gain as a target symptom, both requiring variations in the style, pace, and content of therapy.

Bob M: So then, the key question, if weight concerns are the major issue, and people with eating disorders always talk about the "voices" they hear about how "fat" they are, what is the most effective way of ending those concerns. What should people who want to recover be concentrating on when it comes to that issue?

Dr. Garner: The topic of body weight is approached from an entirely different perspective for anorexia and bulimia nervosa. Experts in the treatment of bulimia nervosa recommend that bulimia nervosa patients should be told that in most cases treatment has little or no effect on body weight, either during treatment itself or afterwards. In anorexia nervosa, this reassurance is not available since weight gain is a major aim of treatment. The significance of this contrast cannot be overemphasized. I do not know how to actually make those voices go away. The first study I did 20 years ago attempted to solve this. Rather, you need to ignore the voices, kind of like a color blind person learning to ignore false signals about color.

Bob M: And when a person feels a relapse or difficult period coming on, what are the most effective ways to deal with that?

Dr. Garner: It should be stressed that vulnerability to eating disorder symptoms can continue for many years, even if there is recovery from eating symptoms. A valuable strategy in avoiding relapse is remaining alert to areas of potential vulnerability. These include vocational stress, holidays, and difficult interpersonal relationships as well as major life transitions. Patients may become distressed if they continue to gain weight. They may also be vulnerable during pregnancy. Patients without any overt symptoms may remain quite sensitive about weight and shape. They need to be prepared for encounters with people who may have seen them at a low body weight. During the termination phase of treatment, patients need to practice adaptive cognitive responses to well intentioned comments like "I see you have gained weight" or "my, how you have changed". Patients may even need to be prepared for occasional callous comments about their weight. Vulnerability to relapse increases during periods of psychological distress. Susceptibility to relapse may also increase with positive life-changes and enhanced self- confidence. Fresh relationships, career advancement, increased physical fitness and overall improvement in self-confidence can activate latent beliefs like "now that things are going so well, maybe I can lose a bit of weight and things will be even better". Patients need to be reminded that weight loss is enticing and insidious in its effects. Initial results may be positive; however, the adverse impact on mood and eating are inevitable over time.

OMC: Why do you think there is no cure for such a deadly disease as anorexia, although it has been researched for generations?

Dr. Garner: Many patients do completely recover from anorexia, just like with other disorders. It has only been carefully researched for the past 20 years.

ZZZ I SHOULD DIE: Which type of eating disorder would you say is the hardest for a person to recover from?

Dr. Garner: Anorexia-- when the person is at a very low weight and is B/V. Starvation effects make it very hard to relate to others and to focus on any aspect of treatment.

Bob M: Here are a few audience comments, then we'll continue with the questions:

Latina: Thank you for making that point Dr. Garner regarding eating disorders being viewed as an addiction. So many individuals with these disorders seem to sell themselves out to the fact that it is a disease or an addiction and that they are untreatable. I understand Donna's point very much. Even recently, I have had family members say that I have only gotten worse over the last five years. But the truth is I had to go to the bottom to rebuild my way back up. I am just surfacing.

ZZZ I SHOULD DIE: I have had an eating disorder for as long as I can remember. I do not remember life without it. I no long want this pain. I am afraid to overcome it for a few reasons. 1) I am afraid to because of the insecurity that I will have; and, 2) I do not want to gain weight (one of my biggest fears).

barbaras: I am 51, raised in an alcoholic and sexually abusive home. I was abducted at the age of 5 by a stranger and raped among other things. I want to quit throwing up, and I have gone as long as 3 weeks, but I always go to another destructive behavior and then back to throwing up and laxatives. I am so tired of fighting this. Is there any hope for recovery?

Aroma: Does Dr. Garner think that nutritional advice is a part of the psychotherapeutic process?

Dr. Garner: Yes. I do think nutritional advice can be helpful. On the subject of relapsing and when to return to treatment: People with eating disorders should have a low threshold for returning to treatment. It is not uncommon for patients to believe that a return to treatment would be a humiliating or unacceptable admission of failure. Common beliefs that interfere with re-initiating therapy are: "I should be able to do this on my own now; if I am having problems again, it means recovery is hopeless; the therapist will be disappointed or angry". Since patients commonly delay the reinitiating of treatment too long, a conservative approach is a good policy. If patients are not sure whether they should return for a follow-up consultation, this means that they should. Sometimes therapists need to define their role as a "family doctor" for eating disorders. Regular "check-ups" are prudent, and meetings at the earliest sign of relapse are the best protection against escalation of symptoms. Remain alert to warning signs of relapse: It is useful to review early signs of relapse with particular attention to weight or shape preoccupation, binge eating, precipitous weight gain, gradual or rapid weight loss and loss of menstrual periods. Patients need to ask themselves periodically: "Am I thinking too much about weight?" Sometimes weight loss occurs for other reasons such as depression or illness.

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HelenSMH: I was wondering, I received treatment called ECT (Electro Convulsive Therapy) for major depression. I don't think it had any effect on my eating disorder, but other inpatient people were getting ECT also for their eating disorder. I was wondering should/can ECT help with eating disorders?

Dr. Garner: ECT is absolutely contraindicated for eating disorders from my reading of the literature.

Suszy: I was wondering why it seems like I'm losing all of my friends over my eating disorder. I'm not hurting anyone but myself?

Dr. Garner: An eating disorder interferes with the ability to maintain social relationships for many reasons. However, unless you have a blueprint for recovery- unless you know how to proceed with recovery, you should not blame yourself for driving others away.

Bob M: Suszy's question brings up another issue: how does one explain their eating disorder to a friend or family member without alienating them?

Dr. Garner: An eating disorder is a problem. Problems can be solved. If it is presented as a solvable problem, rather than an illness, it should help to avoid alienating friends or family members.

Suebee: I recently read that one should not try to lose weight while attempting to recover from bulimia. Is this true?

Dr. Garner: ABSOLUTELY. THIS IS THE KEY!!!!!!

Penny33: Can experiences with bulimia affect bearing children, after a long time of recovery? Also, what areas of your body are affected harshly?

Dr. Garner: As long as recovery is complete, there does not seem to be a problem with bearing children. The long-term effects are unclear. For anorexia, bone loss is a big problem and dental problems can be severe with those who B/V.

clk: What are the side effects of long-term diet pill and laxative abuse and how does an inpatient stay help to gain control over this?

Dr. Garner: Those with eating disorders should be aware of the serious physical complications associated with starvation, self-induced vomiting and purgative abuse. These include electrolyte disturbances, general fatigue, muscle weakness, cramping, edema, constipation, cardiac arrhythmias, paresthesia, kidney disturbances, swollen salivary glands, dental deterioration, finger clubbing, edema, dehydration, bone demineralization, and cerebral atrophy. Laxative abuse is dangerous because it contributes to electrolyte imbalance and other physical complications. Perhaps the most compelling argument for discontinuing their use is that they are an ineffective method of trying to prevent the absorption of calories. An inpatient stay can be helpful in getting you off the laxatives if it is not possible as an outpatient.

Bob M: How common is it for a person to go from anorexia to bulimia or vice versa? And how does having the combination of both affect the chances of a successful recovery?

Dr. Garner: It is very common to move from anorexia to bulimia and less common, but it still occurs, for patients to move the other way. However, the important thing to remember is that the basic issues are similar, a fear of weight gain. Having anorexia and bulimia at the same time is now technically impossible because of the way the diagnositic criteria are worded. However, having anorexia and b/v does not confer a terrible prognosis- the underlying eating disorder is similar regardless of the weight.

hero: What is the treatment used for the compulsive overeater? I have lost and gained my entire life and I'm so tired of a life revolving around food. Can treatment happen without medication?

Dr. Garner: The treatment of choice is 1) not dieting (i.e. 3 meals spaced throughout the day, 2) no less than 2000 calories, and 3) eating former "binge foods" as part of your regular diet. Medication should best be used as an adjucnt to the cognitive behavioral treatments that now have received a great deal of empirical (research testing) support. If you do as I have indicated here, you will NOT continue to gain and will lose weight for the remainder of your life.

Alisonab: When you talked about the weight issue and how we still have a "goal weight"-- well what if we are in a bad medical situation and need to get out of this cycle, but because of the weight issue we cannot. Is there any other way around the weight issue?

Dr. Garner: Almost every bad medical condition is made worse by cycling up and down. I think that the best thing is to aim to stabilize your weight and look for other methods to improve your medical condition.

jbandlow: I've read recently that when an anorexic ingests food, there's a resulting decrease in some brain chemical that can actually cause one to feel worse about having eaten. Is this true? If so, can it be counteracted?

Dr. Garner: I do not think that it is quite this simple. Most anorexia patients feel terrible when they ingest food and this has more to do with feelings about eating and weight gain and loss of control than neurotransmitters. However, we still are in our infancy in our understanding of the effects of eating on brain chemistry.

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luvsmycats: Hi - how do you feel about keeping food diaries?

Dr. Garner: I think that it can be very helpful and meal planning can be even better for those who are really frightened of eating.

JazzyBelle: Why do people sometimes go to cutting themselves if they have an eating disorder?

Bob M: We are talking about self-injury here. And it seems that for some, eating disorders and self-injury go hand-in-hand.

Dr. Garner: Self injury occurs in about 15% of eating disordered patients. There are several reasons. 1) to increase pain to wipe out other feelings. 2) to increase sensations in those who are having trouble experiencing feelings, 3) to control others, since it elicits such strong reactions, and the person does not feel that she has any other way to achieve control.

Bob M: I'm not familiar with this part of the research, but are people genetically predisposed to having an eating disorder and/or does it seem to "run" in families? So, if I have an eating disorder, do I have to worry about my children having one?

Dr. Garner: There is evidence that eating disorders run in families. For example, anorexia occurs in 10% of sisters and fraternal twins, but 50% of identical twins. Moreover, children of those with eating disorders have a greater chance of developing eating disorders, but is this related to genes or to teaching the child things that make an eating disorder more likely? This remains unknown.

Bob M: We haven't touched on this part either yet...what about men with eating disorders. Do they face different issues when it comes to recovery? And is it any harder/easier for men to recover and do they suffer more/fewer relapses? Why?

Dr. Garner: Men face different issues since eating disorders are often thought of as "women's disorders" which can make it more difficult for men to seek treatment for their eating disorder. Also, there has been research suggesting that sexual identity conflict issues are more common among men with eating disorders. Arnold Andersen at the University of Iowa has done a great deal of research on this topic. It does not appear that men are less likely to recover. I just want to say before I sign off that, after working with people with eating disorders for years, I am really optimistic about the prospects for recovery. Every patient should know that recovery is possible, even after many years of serious illness.

Charlene: What can one do when not actively engaging in eating disordered behavior, but you are still constantly bothered by the thoughts? Is there anything besides costly therapy?

Dr. Garner: We have had two patients in our program recently who have had an eating disorder for 20 years and have made extraordinary progress in recovery. Not everyone makes this type of progress, but then, these patients who have made progress did not know they were going to do well until after participating in treatment. Thus, I encourage everyone to keep trying and to keep the faith in the possibility of recovery and a life without an eating disorder. I want to thank Bob and Concerned Counseling for providing this opportunity to discuss recovery- Now to Charlene:

If the thoughts are really intrusive, then I think that continued treatment would be helpful. Consult your Dr. for an opinion and recommendation. One assessment should not be that costly. I would not underestimate the pain caused by thoughts and they may very well warrant treatment. Best wishes, Dr. Garner.

Bob M: We had over 150 people coming in and out of the conference and I know we didn't get to everyone's questions. I want to thank Dr. Garner for being here this evening and for sharing his knowledge and information with us. And thank you to everyone in the audience who came tonight. I hope everyone has a good rest of the week. We have many people with eating disorders, all three, anorexia, bulimia, compulsive overeating who visit our site everyday. So if you are needing or wanting to give support, please stop in.

Dr. Garner: Good night and thanks Bob for providing me with this opportunity.

Bob M: Good Night everyone.

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Bob M: Good evening everyone. Our topic tonight is BODY IMAGE. We are going to be discussing the psychology of body image and why some people have positive one's and others have a negative image. And then, our guest will tell us how we can work towards developing a more positive image of our bodies and ourselves. I'm Bob McMillan, the moderator for tonight's conference. Our guest is Carolyn Costin. Carolyn is the Director of the Monte Nido Treatment Center in California. She has also written several books on the subject of eating disorders. Good evening Carolyn and welcome to the Concerned Counseling website. We appreciate you being our guest tonight. Can you please tell us a bit more about your expertise?

Carolyn Costin: Good evening. Thank you for having me. I have been an eating disorder therapist for approximately 20 years and I am also a recovered anorexic. I have developed and implemented 5 treatment programs, most currently my six-bed residential program in Malibu.

Bob M: Just so we are all on the same track tonight, can you please define "body image" for us?

Carolyn Costin: Body image refers to the body as a psychological experience and focuses on the individual's feelings and attitudes towards their body.

Bob M: I hear all the time that poor body image can lead to an eating disorder. What I want to address tonight is: what creates a poor body image?

Carolyn Costin: There are a variety of causes. We first look at how a person's caregivers treated their body when growing up. For example, was the person attended physically, were they touched, what comments were made about their body, all the way to were they neglected. Then we have cultural issues such as our current "thin is in" society where women are portrayed as unrealistically thin in the media. It is a complicated issue.

Bob M: It is. What I want to do is try and break it down into components, if we can? At what age does a person begin to take notice of their bodies? And at what point does it begin to have an impact on their self-image?

Carolyn Costin: Let's start with the components. We can break down body image into 3 separate aspects. There is perception, attitude, and behavior. Perception is what the person sees when they look at their body. Attitude is their feelings about what they see, and behavior is what they do about their attitude. From birth, babies take notice of their bodies. In fact, this is the way they begin to formulate a separate sense of self.

Bob M: Are you born with a positive body image and then it changes because of external or environmental factors?

Carolyn Costin: That sounds like a good way to describe it, but perhaps it is better to say we are born with a neutral body image and our experiences begin to shape how positive or negative our body image will be.

Bob M: Our topic tonight is BODY IMAGE. For those just joining us, our guest is Carolyn Costin, director of the Monte Nido Eating Disorders Treatment Center in California (Eating Disorders Treatment Centers). I know that many of you in the audience have eating disorders, but we are limiting tonight's conference to Body Image and related questions. Here are a few audience questions Carolyn:

Mick31: How can we change our body image from negative to positive?

Carolyn Costin: First of all, it depends on the roots of the negative body image. For example, if someone grew up in a family with poor boundaries, they may have developed a need to over-control their body. For example, what goes in and what goes out (food/exercise). However, one can begin to focus on what the body does that is positive. For example, I often have clients make a list of the positive things about having a body, or interview their bodies. This begins to reconnect them to owning and appreciating that they have a body. Usually people need to work with someone as this can be very difficult. Traditional body image assignments given to patients such as draw your body, often don't work because they re-enforce our focus on the body's appearance.

Bob M: How is it that a person develops a "warped" sense of their own body? For instance, someone with anorexia, who is very thin, sees and thinks of themselves as being fat.

Carolyn Costin: In anorexia nervosa, body image disturbance increases as the illness progresses. It usually begins when the person feels that their body is too big compared to some standard ideal. We also think that there may be a genetic predisposition in some individuals which causes them to have perceptual distortion. Lastly, it seems that nutritional deficiencies may contribute to body image disturbance. It often appears that the thinner these girls get, the fatter they feel.

Ayah: What is a positive body image? Accepting myself as I am? It's kind of an abstract concept to a lot of us I think.

Carolyn Costin: Yes, I agree it is a very abstract concept. What I try to do in my work is to help people to commit to not doing anything destructive in order to have a "better body." I think it is hard in this society to accept our bodies as we are always told by the media through advertisements and fashion models that we are not good enough. It's one thing to try to improve our bodies in a healthy way, but it is very important not to ever put our health and well-being in jeopardy just to look a certain way.

Celina: How do we view ourselves in a better light, when in reality I'm disgustingly fat!!

Carolyn Costin: The interesting part here is the word: "disgusting". Who told you, or who decides, that one size is disgusting and another size is attractive or ideal? If you want to change your body, and you can do it in a healthy way, for example, increased activity, than that would be fine.

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Froggle08: Carolyn, you are saying why we feel this way and medical explanations, but how do we stop these things? How is one not to feel negative about their bodies when they hear that they are fat?

Carolyn Costin: I admit it is hard. People are in treatment for this. I will not be able to tell you over the internet, but I can make some suggestions. For example, a very good book is When Women Stop Hating Their Bodies. This would be good for men and women to read. You may need to seek professional help. Also, try to find an activity that you enjoy doing where you use your body.

Bob M: Here are a few audience comments:

metaphorical eyeball: How can you change the minds of young girls like myself, when the media is always in our face about losing weight and being the thinnest?

Con: I am not sure if what I have is poor body image or not. I was abused, sexually, as a child and I hate how my body reacted and it seems that hate is so deep within me. I am anorexic and I seem to always be trying to get rid of my body which betrayed me.

JoO: I think what you are telling us is that we have a body. Some of us have become victims of what society tells us is about the kind/shape of body we should have. We have forgotten to look at the people/person we are. What we should be focusing on is the person we are inside and just being the best we can. Keeping up positive attitudes and not going for what everybody else calls normal. BUT -- so saying -- this is hard to do and I would say the problems have to be dealt with first. Does any of this make any sense?

Joan: Carolyn -- you are talking that anorexia body image increases as the illness progresses....I sincerely believe that ALL eating disorders increase, whether it be a perceived weight problem or an actual weight problem. Emotional pain is emotional pain.

Avalon: Even with professional help, it does not help when it's people that are the cause of the problem. When your jeans are not the size that they want for them to be.

Carolyn Costin: I tell all my clients not to buy fashion magazines or any other magazine that only shows thin bodies. Support magazines like "Mode." This is a very good magazine showing bodies of all sizes. Please write to television shows and magazines and tell them how you are affected by seeing only thin bodies. Body image dissatisfaction is rampant in our society. We have 80% of fourth grade girls going on diets and about 11% have used self-induced vomiting. I think we need to start with children very young. We need to focus on their souls and spirits, not their bodies. We need to help children and each other to focus on internal instead of external qualities. This is why I wrote the book, Your Dieting Daughter.

Bob M: But what about professional treatment...is that what it takes to correct a poor body image, or can someone work through that on their own?

Carolyn Costin: Depending on how severe the body image disturbance is, professional help may or may not be required (eating disorders treatment). If it is affecting your behavior, for example, inadequate nutritional intake, vomiting, taking laxatives, or other self-destructive behaviors, you should seek professional help. In some cases, self-help books, participating in sports, and increasing self-esteem in other areas might be enough.

Bob M: Here are a few audience comments, then more questions:

Fazz: Feeling this hate towards the body is so ingrained by our system that it becomes a reflex action. It's then very tough to overcome.

Suey: That's easy to say. Teach the kids when they're young, but it goes so much deeper than just physical looks!!

Freestyle: I think a person can work through it a lot on his/her own. The truth sets you free, no matter where you find it or who points it out. There are some really good books on the market now too to help.

tennis me: What are we supposed to say to our kids so we do not recreate another generation of people with poor body image and eating disorders?

Carolyn Costin: Time is too limited to tell you everything to say, and I want to be helpful, so I'll refer you to some very good books on the subject. Making Peace with Food, by Susan Kano, How to Get Your Kid to Eat But Not too Much, by Ellen Satter, Father Hunger, by Margo Maine, and my book, Your Dieting Daughter, will also help. In addition, it is important for parents to avoid making negative comments about their own bodies, or judgments about other people's bodies in front of their children. I do not think parents should keep scales in their homes. If a child seems to have a problem with being overweight, make sure to focus on health, not looks. Point out to children role models in all shapes and sizes.

Freestyle: I tell my daughters that so much of what society teaches is just plain false. Being thin, in and of itself, won't make you happy. It won't make them rich. It won't find them Mr. Right. It won't get them a perfect job. I try to point them in the direction that will get them these things: being kind and fun-loving and getting an education and caring about others.

macbethany: My mother always praised my good looks and that made me feel very uncomfortable. I was so self-conscious growing up (am 24 now). I also feel she used to stare at my body as I developed. Could this be why I have a bad body-image?

EDSites: Do you feel that the "all or nothing" thinking plays a part in how a person will view themselves? For me, if I fail at something it tends to turn into how I feel about myself physically. How can one change that?

Carolyn Costin: People often turn real feelings into feelings about their body because the body seems easier to control. I ask people to write about any feelings they have prior to engaging in any disordered eating behavior.

Bob M: The Monte Nido Treatment Center is in California. Here is the site address for them: http://www.montenido.com. I know it's getting late Carolyn, so we will wrap it up. We all appreciate you being here tonight. Thank you for coming and being our guest.

Carolyn Costin: This is a tough topic, but I want everyone to know that they can get better if they suffer from a body image problem. It took me a few years, and it may take more time for others, but you can reach a point where what you weigh, or what you look like, is not more important than who you are. Thank you, Bob.

Bob M: Good Night everyone.

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