Anorexia

Anorexia: What You Should Know

Your loved one just picks at the food, shoving it around on the plate, sneaking it to the dog, making excuses or just straight up lying to you about eating.  The lying is new behavior in a person who has always been honest and forthright; a highly successful individual by any standards. But now s/he is struggling to keep up with even the basics like self-care, social activities, school or work. Friendships seem to be a thing of the past and any activity having to do with eating is an excruciatingly painful experience.  Getting her or him to go out to dinner or to a family event is next to impossible.  It’s as if s/he never feels well anymore, no energy and something always seems to be wrong; headache, stomachache, nausea…always something.

Then one day you see your loved one in a bathing suit or underwear and you know something is wrong.  Very wrong!  You are looking at a scarecrow….nothing but skin and bones.  Is it cancer?  Is she doing this on purpose?  Does he know how thin he is?

More importantly, what do you do? 

Understanding what you are dealing with is a good place to start.  Here are a few things to keep in mind.

  1. Anorexia nervosa psychosis is the technical diagnosis although it has now been shortened to Anorexia.  The original diagnosis included “psychosis” because the Anorexic does not appear to know that there is a problem.  The denial is so intense at times that it defies reason or reality.  I have treated adults who weighed 65 pounds and believed that they were overweight.  

To the Anorexic, starvation is a solution to a problem, which is the anxiety caused by eating.  The calmness s/he experiences with starvation becomes addicting.  

As crazy as that sounds, there is a scientific reason for this.  Starvation causes a chain reaction that intensifies anxiety when the individual suffering from Anorexia re-feeds.  

Here is how it works.  Restricting causes the body to stop producing L-tryptophan, which is needed to produce melatonin and also serotonin.  Serotonin is the neurotransmitter that regulates mood.  Too much of it and we are off-the-chart anxious.  Too little of it and we are depressed. 

What does this have to do with Anorexia?  Since starvation results in less L-tryptophan and ultimately too little Serotonin, the body compensates by making more Serotonin receptors.  The body’s logic seems to be that if there are more receptors, there will be more Serotonin available.  Amazing the way the body tries to adapt when we mistreat it, right?  

One problem though, it backfires when the individual re-feeds (initially).  In other words, the increased sensitivity from having more Serotonin receptors causes irritability, anxiety, panic and even rage when the individual eats, because the body starts to produce L-tryptophan again which ramps up the Serotonin to a level that is too high.  At this point there is too much Serotonin and we have, in effect, the equivalent of a panic attack every time the individual suffering from Anorexia eats.

I cannot tell you how many times I have heard my Anorexic patient describe the self-loathing s/he feels while eating.  Or the irritability and rage.  Often during the initial stages of re-feeding, the individual suffering from Anorexia must eat alone in order to manage the intensity of these feelings.  Even then it is a struggle.  A crucial part of the success of my approach is to help family members be patient and give their loved ones the space they need during these times.  

Families or practitioners, who see this behavior and label it as obstinate or resistant, miss the boat and can make matters worse for the patient. Many patients tell stories of having their primary care practitioner tell them to “just eat.”  This tends to be infuriating, insulting, and depressing for someone who experiences real terror while eating.  Worse still, I have been privy to residential facilities that actually punish the fearful behavior by putting the patient in isolation or tube feeding him or her to force “compliance.”  Obviously, that did not work or I would not have been working with that patient.  

Likewise families that insist that their love one sit down to dinner with them no matter how much anxiety it causes, can make recovery harder for the individual that needs privacy while eating to get through this phase.  And it is a phase.  It may last a month or a year, but it passes eventually, as long as the individual is no longer restricting.  

For the individual who is still restricting consistently or even intermittently, the problem continues and often gets worse as a very vicious cycle is set in motion. The longer and more frequently s/he restricts, the more anxiety and rage s/he experiences while eating, which reinforces that eating is bad.  Understanding the science behind the anxiety and anger really helps the patient as well as the family member who is almost always just trying to help.

2. Eating “clean” is also essential to recovery because so many of the pollutants in today’s foods attack the gut, causing even more anxiety, and damaging the parts of the brain that regulate eating behaviors.  For example, Monsanto’s Roundup, which is sprayed on GMO crops, shuts down something called the Shikimate pathway. 

The Shikimate pathway is what our gut bacteria use to produce the vast majority of the L-tryptophan that we need. As we saw above, L-tryptophan is a precursor to melatonin, and ultimately to serotonin…..and we are back to the anxiety again.  Lowering L-tryptophan leads to an increase in Serotonin as the body tries to compensate. The other metabolite of L-tryptophan, Melatonin, is linked to sleep and circadian rhythms, which can also become disrupted for those who are eating a lot of conventional food.

Polluted foods also attacks the parts of the brain that regulate eating behavior.  MSG and high fructose corn syrup are both neurotoxins that  are found in almost every processed food and even in some “organic” foods.  The problem is that they are powerful addictants as they excite glutamate receptors, the same receptors that allow us to become addicted to drugs of abuse.  It is hard to buy a processed food that does not contain one or both.  

Some individuals suffering from Anorexia become addicted to processed foods and sugar because they are avoiding fat and low fat foods are often loaded with sugar.  This can lead to a new disorder, Bulimarexia, which combines restricting, bingeing and then purging.  It is not yet officially a diagnosis despite how common it has become, that involves restricting, bingeing and purging. This is a very dangerous condition, causing even more complications than Anorexia or Bulimia alone.

Bottom line: for my patients who embrace clean eating, recovery is faster and relapse is rare.  For those who do not embrace clean eating, recovery takes much longer and relapse is much more likely.

3. Anorexia has the highest mortality rate of any other emotional disorder.  The crude rate of mortality due to all causes of death for subjects with anorexia nervosa in these studies was 5.9% (178 deaths in 3,006 subjects). The aggregate estimated mortality rate for subjects with anorexia nervosa is substantially greater than that reported for female psychiatric inpatients and for the general population.

Anorexia isn’t well understood. Many well-intentioned practitioners behave as if the victim chooses to be Anorexic or worse, give such sage advice as “Just eat.” Anorexia is a very serious disorder that takes over the victim’s life, and if treated unsuccessfully may actually end it.

Treatment Approach

LINK TO SERVICES PAGE

Dr. J. Renae Norton offers Individual and family therapy for the treatment of eating disorders and obesity.  As a family systems practitioner, she also offers treatment for relationship problems for families and couples.  

One thing that sets her apart from other practitioners when it comes to eating disorders is that she offers an alternative to residential treatment called Intensive Outpatient Program (IOP.)  Her approach offers several advantages over residential and other semi-residential or IOP programs:

  • Patients can usually remain in school, or keep their jobs while in treatment because treatment is more targeted.
  • Patients get 5 to 10 hours of actual therapy with a licensed psychologist, Dr. Norton, instead of 1 hour of therapy, as is the case with the majority of residential and semi-residential programs.
  • Patients learn to shop for and prepare clean scrumptious foods that heal the body and allow for a slow but steady weight gain.
  • Norton has adapted Dialectical Behavioral Therapy by Marsha Lenihan, to the treatment of eating disorders, which many patients have found to be life saving when it comes to regulating emotions
  • Norton is a family psychologist, which is critical to the success of treatment. Anorexia begins within the context of the family. Healing often takes place there as well.  A 2010 study compared the success of individual therapy and family-based therapy and family therapy offered a distinct advantage over individual therapy.[1]

Anorexia: How It Starts

In my experience, Anorexia doesn’t just happen, it occurs for a reason, or a combination of reasons, often to correct something that is out of balance in the patient’s life; an injury that ended dreams of being an accomplished athlete, dancer, or skater. Maybe it was an obese childhood and the stigma of being obese which resulted in the determination that it will never happen again.  Or perhaps the individual felt abandoned figuratively or literally, and the eating disorder was a way to get the attention needed to feel safe.

Many people suffering from Anorexia have debilitating anxiety.  As we saw above, the anxiety may start out as a gut issue having to do with Serotonin levels that are out of whack.  Even if it starts that way, it will usually take on a life of it’s own.  The Anorexia provides such individuals with a focus, being as thin as possible, and a solution, restricting.

Extreme perfectionism also plays a role with most Anorexics, who aspire to be the best Anorexic ever.  To this end they feel ashamed when they are not restricting, or worse, when they are gaining weight, as it means that they are failing.

There is a myth that Anorexia is a disorder that only impacts teenage girls, but the latest research shows that it can begin at any age. Today it is affecting younger children, older women and more men.

 Primary Features of Anorexia

Whatever the cause, the primary features of Anorexia nervosa are:

  • Refusal to maintain a healthy body weight
  • An intense fear of gaining weight
  • Distorted body image – called body dysmorphia, such that she may still see herself as “fat” at 60 pounds

How It Feels

Lonely. You have lost your friends. Your parents and/or your significant other go back and forth between begging you to eat and threatening you if you do not. They definitely do not have a clue about the “twisted” way your Anorexic mind is working. Your every waking moment is dedicated to the pursuit of thinness. You (or the vicious voice in your head) never stops. It is relentless. It makes every situation involving food a nightmare for you and your loved ones. But you have to keep all of this to yourself. No one seems to get it how afraid you are. They all think you are being “stubborn”. You are losing everything. But you cannot see a way out, or a way back.

What to Look For in Your Loved One

These are just some of the characteristics that accompany Anorexia.  Please understand that everyone is different and that this is not a One-Size-Fits-All sort of problem.

  • Restricting food intake despite being thin – Following a severely restricted diet. Eliminating “fats” or “carbs”. Eating only certain low-calorie foods. Refusing to eat around others or in public places.  Having a “good” and “bad” food list where the “good” foods are fewer and fewer over time. It can get so extreme that the Anorexic is afraid to drink water.
  • Food rituals –Eating in rigid, ritualistic ways, such as cutting food into tiny pieces; eating at certain times and if that time is missed, not eating; eating only with a particular set of utensils; chewing food and spitting; eating alone and if anyone enters the meal is over.
  • Pretending to eat or lying about eating –Suddenly becoming vegan, always having stomachaches.  Hiding, playing with, or throwing away food. Making excuses to get out of meals.
  • Preoccupation with food – Some individuals, especially those suffering from starvation syndrome, cannot stop thinking about food and may engage in food related activities such as cooking for others, collecting recipes, reading food magazines, or making meal plans while still eating next to nothing themselves.
  • Obsession with calories, fat grams, and nutrition – Reading food labels, measuring and weighing portions, keeping a food diary, surfing the net for low calorie diets/foods.
  • Dramatic weight loss – Rapid or drastic weight loss with no medical cause. It may start out as seeming completely normal, s/he was a bit overweight and went on what appeared to be a “healthy” diet. (Diets are never healthy.) But there was no end and s/he could not stop losing weight. What was once a diet, is now an obsession.
  • Feeling fat, despite being grossly underweight – Many though not all individuals suffering from Anorexia or Bulimarexia suffer from body dysmorphia, or a belief despite all evidence to the contrary, that they are fat. Sometimes the focus is a particular body part, usually the stomach but it can also be legs, hips, or thighs.
  • Fixation on body image – Most patients really believe that other people are harshly critical of the way they look. They may obsess about every aspect of their appearance or something specific such as body shape, or clothing size.
  • Harshly critical of appearance – In some cases the individual spends so much time in front of the mirror that they cannot function. It may take hours to get ready. Others cannot bear to look in a mirror and must cover the bathroom mirror up in order to shower.  Some individuals do not apply makeup and where baggy even wrinkled clothes.  In either case, there is always something to criticize. You’re never thin enough.
  • Denial – The denial is fierce. It is one of the reasons that this disorder is considered to have psychotic-like symptoms, because the break with reality is so significant. It is very sad to see how this plays out. Many people are frightened of Anorexia.  Unaware or unable to express their fear, they appear instead to be offended by the person who refuses to eat. But the Anorexic/bulimarexic misinterprets their fear as disgust and believes that they are disgusted with her for being too fat.

Residential Treatment vs Outpatient Treatment Outcomes

I am not a proponent of residential treatment for Anorexia.  I have seen too many examples of exploitation and too little benefit or recovery.  If you think about it, it doesn’t make much sense.  How is someone going to recover from a psychiatric illness that is more difficult to treat than any other in 21 to 30 days?  That is the average length of stay in residential treatment because that is all that insurance usually pays.  And the cost is outrageous, especially when you consider the amount of actual treatment most patients receive while inpatient. 

According to Eating Disorder Information the average cost is $1000/day and monthly expenses range from $25,000 to $50,000 per month.  I have patients that have paid $1500/a day and for that they saw a licensed practitioner for ½ hour each week.  The rest of the time they spent doing art, having group sessions where they learned how to be a better Anorexic because they compete with each other, and watching TV.  The 30-day limit at a residential treatment facility is arbitrary, having nothing to do with the length of time that it takes to recover from a serious eating disorder, but driven instead by how much insurance companies will pay. 

This is what the research shows when it comes to residential treatment:

Treatment Outcomes for Anorexia Nervosa[2]

Well at:               2 years/whole group                 5 years/whole group 

 Inpatient                                      17.2%                                  33.3%                                   (Ind. & Fam)

 Outpatient                                 20.0%                                         47.1%                                         (Ind. & Fam)

Another pet peeve of mine is that residential patients are not fed “clean” foods.  In fact the opposite is true.  They are actually encouraged to eat foods like Reese Cups and bagels to help them overcome their fears of eating.  This is so wrong given the damage that sugar, especially the high fructose corn syrup found in a Reese Cup, and the bromated flour found in a bagel can have on the parts of the brain that regulate healthy eating.  

I have yet to find a treatment center that offers organic food to a population that is likely at risk partially as a result of eating polluted foods.  

My outcomes are better.  If they stay in treatment, 90% of my patients begin to recover within the first year.  If they embrace clean eating only a very small percent relapse.

I look for small gains and great results.  Most residential treatment centers do the opposite; they want a weight gain of 20 pounds in 21 days and to heck with what happens after that.  They can claim that their patient “got well.” Who could be comfortable gaining 20 pounds in such a short period of time?  But imagine the trauma for someone who is Anorexic.

This is only one of the reasons that residential treatment does not work. It also does not generalize well to the patient’s life at home, as s/he has not learned the coping skills necessary to correct the problems that may be driving the anxiety that drives the Anorexia.  In other words the skills to survive in residential treatment centers are very different from the skills needed to survive in one’s real life. Polluted foods, school or work stressors and unresolved relationship issues must also be a part of treatment.

The Impact Families Have

Although there is research showing a correlation with an overprotective mother and a critical father, this is certainly not always the underlying dynamic. To the contrary, there are many things that can result in life-threatening eating disorder.  

That said, in my experience, parents are almost never neutral. They are either helping or hurting, no matter how well-intended they are. In fact the “best” parents can have the worst impact, because they try harder. So if what they are doing is not working despite their best intentions, and they try harder, the effect is opposite of what they intend, making matters worse.

This is why it is so important to involve the family and significant others in the treatment process. Research consistently points to the value of family involvement and yet the vast majority of professionals treating these disorders do not appear[3] to include family members as part of the treatment. 

Some practitioners go to great lengths to prevent family involvement in a misguided effort to protect the privacy and confidentiality of the patient. While both privacy and confidentiality are of the utmost importance, they do not have to be violated in order to use a family-based approach.[4]

A Family Systems Way to Look At Anorexia

Systems theory tells us that in order to solve a problem we have to use the right set of assumptions. Further, it tells us that if we use the wrong assumptions, the problem will continue to get worse. In other words, if you do not understand the Anorexic’s assumptions, (and most do not) everything you do makes the problem worse.  Sound familiar?

For example, for many suffering from this terrible disorder, the problem is surviving in spite of an intense and irrational fear of maintaining a weight that is sufficient for survival. The assumption may sound like “No matter how much weight I lose, I can still cheat death.” Based upon this assumption, systems theory, which looks at duration, frequency and intensity might dictate the following thoughts about eating:

  • Duration of eating – “I will only eat for 30 minutes….. I will only eat for 20 minutes…. I will only eat for 5 minutes out of every day…”
  • Frequency of eating – I will only eat once a day……I will only eat every two days……I will only eat once a week.
  • Intensity of restricting – I will only eat 700 calories….. I will eat only 500 calories…. I will eat only 100 calories today.

In other words the restricting escalates out of control based upon the assumption, which is incorrect, i.e. I can continue to lose weight and not die. 

A new underlying assumption would take into consideration the fact that the body must have fuel to function and that survival is more important than relentlessly losing weight. It would sound like: I cannot continue to lose weight without risking death.

“This is one of the first questions I ask my Anorexic patient: Do you want to die? They almost always say no. Once we have this established, we can begin to challenge the original inaccurate assumption.” Dr. Renae Norton

This is known as reframing the problem. When the new assumption is applied, restricting all food intake in order to continue losing weight is no longer an option.

Where Things Run Amok in Recovery

Note, however, that if the new underlying assumption only goes as far as survival, (and not as far as attaining good health) the individual will now eat only enough to maintain his or her weight at a level sufficient to sustain life, and not enough to gain the additional weight needed for good health.

This happens a lot and it causes problems for the novice therapist as well as for the family, who have different definitions (underlying assumptions) of “recovery.” If the therapist assumes “recovery” means achieving a normal weight, and the patient assumes that “recovery” means achieving only enough weight to survive, the two could be 20 or 30 pounds apart, and light years away from solving the problem together. 

When I am coaching other therapists, this is one of the most common scenarios. If the underlying assumptions of the therapist and the patient differ, they can seriously disrupt the therapeutic relationship, sometimes to the point of no return.

If your loved one has been in treatment with a therapist that seemed very judging, it may be because of this dynamic at play. If the actual weight the patient is willing to gain is significantly less than the weight the therapist deems necessary, it may cause the therapist to feel frustrated and/or angry.  Most therapists get very anxious when their patient almost dies, and some handle the anxiety better than others. Treating AN is not for the feint of heart. It is distressing to sit across from a 70-pound person who politely refuses to eat.

Of course it is even more difficult for the family members, when they realize that their loved one is not going to gain more than necessary to barely maintain life. If they do not understand the underlying assumption of the patient, they may misinterpret the patient’s behavior as manipulative.  What they observe is that, while in the hospital, (or residential treatment center) the patient suddenly becomes compliant about eating. The erroneous assumption practitioners and family members often make is that s/he must have seen the light.

That is generally not what is happening.  Residential patients are often simply trying to get out of the residential setting so that they can feel in control again. When family members realize that the compliant behavior lasts only long enough for the individual to get out of the hospital, off the IV feed, or feeding tube, and back home where s/he has total control, they feel manipulated and/or angry.

If this is the reaction, the timing couldn’t be worse for the patient, who has actually had a breakthrough. In these circumstances, s/he recognizes that there is a point beyond which it is not safe to continue losing weight. In addition, it takes guts for any patient suffering from AN or Bulimarexia, to eat enough to gain weight, no matter what his/her intentions are for maintaining it.  In other words, it’s a start.

In treatment, I help family members understand that this is a good thing, as it breaks the relentless pattern of losing weight and it means that their loved one is not suicidal.

But the fear is so great for family members that they may express disappointment. It isn’t uncommon for parents to say: “If you don’t care about yourself, why should we?” This is more likely to happen when it isn’t the first time that their loved one has had to be hospitalized and/or if paying for treatment comes at great personal sacrifice for the family.

Solution: In the alternative, as a family systems therapist, and someone that understands the underlying assumption(s) of the individual suffering from Anorexia, reframing what is happening for the family, reassuring them that this is normal and a good first step towards recovery is more helpful.

As to the patient, the most common underlying assumption getting in the way of recovery is that “If I start eating, I will never be able to stop.”  I believe that this assumption is driven in large measure by the polluted nature of the American food supply, which is loaded with addictants and obesogens.  Many of my patients began life slightly or even significantly over weight and they never want to go there again.  Enter clean food, the way it was intended, whole, unpolluted and nourishing.

I believe that this is central to the reason that my patients get well and stay well; Clean food behaves, it does not cause a food baby, tear holes in your gut or attack the parts of your brain that cause you to binge and gain weight. It is not addicting or obesogenic.  Clean food has scientifically been shown to cause less weight gain than the same amount of polluted food. 

Resting Metabolism Rate (RMR)

One of the most common fears the Anorexic has is uncontrolled weight gain.  There is actually some basis for this fear of uncontrolled weight gain from a biological perspective. Victims of AN and Bulimarexia have often suppressed their metabolism, by restricting for years, to the point that rapid weight gain may begin with relatively low caloric intake. This is, of course, part of another very vicious cycle. The less they eat, the less they can eat without gaining weight. If left unaddressed, this underlying assumption, which is based on a biological reality, will undermine recovery.

Research demonstrates that rapid weight gain is counterproductive with this population. I find that re-feeding goes much better when it begins with my client’s current resting metabolism rate (RMR) and systematically, but very slowly, steps up the calories over a period of 12 to 18 months, which also improves a sluggish metabolic rate. I am comfortable with one or two pounds of weight gain per month, as long as s/he is medically stable and the calories are consistently going up each month and I know that the food is clean and loaded with great nutrition.

The focus is on increasing the calories each week with clean food. The focus is not on the weight gain per se.  In fact, most of my patients are eating 2 to 3 times the number of calories within the first month with little or sometimes even no weight gain, because their metabolism rate improves almost immediately on a clean diet.   

Of course, ultimately there is weight gain, but it is reassuringly slow from the patient’s perspective, despite the fact that the calories are going up fairly quickly. A typical scenario is that of patient LL.  For this particular patient, her initial RMR was 693 calories per day, and her weight was 79 pounds, while her RMR at the end of eleven months was 1940 calories per day and her weight was 99.[5]

I often see such dramatic changes in the resting metabolism rate, which I track for every patient that is re-feeding. The graphs are both convincing, as well as reassuring to the client and her loved ones. The value of this approach is that it does not ask for a change that would challenge all of his/her underlying assumptions and create resistance (by triggering tremendous anxiety). Instead, it accepts the patient’s underlying assumptions, and leverages them into progressively more healthy behavior. As a result, there is less danger of setting up resistance (not eating), which often leads to rebounding (weight loss).

Unfortunately, this is exactly what happens in residential treatment centers. Even in outpatient therapy, many therapists communicate a similar expectation to their patients, i.e. that s/he should gain weight rapidly. To this end, the patient is weighed every visit and the criteria for a successful week is based solely upon his/her weight gain. It may have the unintended side effect of forcing the patient to lie to avoid the negative consequences of telling the truth.

Resources

Characteristics of Anorexia from: National Women’s Health Information Center

  • Behaviors focused around food preparation and planning (e.g. shopping for food, planning, preparing and cooking meals for others but not consuming meals themselves; taking control of the family meals; reading cookbooks, recipes, nutritional guides)
  • Strong focus on body shape and weight (e.g. interest in weight-loss websites, dieting tips in books and magazines, images of thin people)
  • Development of repetitive or obsessive body checking behaviours (e.g. pinching waist or wrists, repeated weighing of self, excessive time spent looking in mirrors)
  • Social withdrawal or isolation from friends, including avoidance of previously enjoyed activities
  • Change in clothing style, such as wearing baggy clothes
  • Deceptive behaviour around food, such as secretly throwing food out, eating in secret (often only noticed due to many wrappers or food containers found in the bin) or lying about amount or type of food consumed
  • Eating very slowly (e.g. eating with teaspoons, cutting food into small pieces and eating one at a time, rearranging food on plate)
  • Continual denial of hunger
  • Physical warning signs
  • Sudden or rapid weight loss
  • Frequent changes in weight
  • Sensitivity to the cold (feeling cold most of the time, even in warm environments)
  • Loss or disturbance of menstrual periods (females)
  • Signs of frequent vomiting – swollen cheeks/ jawline, calluses on knuckles, or damage to teeth
  • Fainting, dizziness
  • Fatigue – always feeling tired, unable to perform normal activities
  • Psychological warning signs
  • Increased preoccupation with body shape, weight and appearance
  • Intense fear of gaining weight
  • Constant preoccupation with food or with activities relating to food
  • Extreme body dissatisfaction/ negative body image
  • Distorted body image (eg. complaining of being/feeling/looking fat when actually a healthy weight or underweight)
  • Heightened sensitivity to comments or criticism about body shape or weight, eating or exercise habits
  • Heightened anxiety around meal times
  • Depression or anxiety
  • Moodiness or irritability
  • Low self-esteem (eg. feeling worthless, feelings of shame, guilt or self-loathing)
  • Rigid ‘black and white’ thinking (viewing everything as either ‘good’ or ‘bad’)
  • Feelings of life being ‘out of control’
  • Feelings of being unable to control behaviors around food

LINK TO RE-FEEDING PLAN:

Whether the issue is restricting or bingeing and purging, learning how to eat without fear and dread is the key to recovery. Dieting doesn’t work, restricting can lead to death and bingeing and purging do not control weight and may also cause serious medical complications, some of which are irreversible.

What works is learning to eat clean nutritious foods that do not pollute the body or cause unnecessary weight gain.  Assuming that the client is medically stable, weight-bearing and light aerobic exercise 3 to 4 times per week is essential to good health. When regular exercise is combined with eating clean foods, a healthy relationship with food and eating can be established.

Re-feeding addresses several issues, food phobias, food allergies/sensitivities and the quality of the food.  Food phobias are usually based upon misperceptions and/or mistaken beliefs about fat and carbohydrates. A critical component of treatment is debunking the myths and fears about foods and desensitizing the individual to the ingestion of healthy foods. When the client is ready, analyzing her current food intake is the first step towards managing this component of the eating disorder.

Food allergies and sensitivities are also of critical importance as they may attack the gut or the thyroid.  If this is happening it increases the anxiety that my patient is experiencing making it even more important to hang on to her coping mechanism, restricting. I recommend a comprehensive medical assessment to rule out thyroid disorders, vitamin D deficiencies, esophageal tears from purging, osteopedia or osteoporosis, heart arrhythmias, upper or lower GI problems from laxative abuse, which are very common among those with an eating disorder, and food sensitivities that may be a contributing factor to food aversion.

Finally re-feeding focuses on understanding and learning to enjoy “clean” food.  The following is a clean eating/re-feeding protocol that should be standard for anyone who is recovering from Anorexia.ing Request

Re-feeding Plan

Protein– Six servings of protein /day = 3 meals + 3 snacks.  Have 4 to 6 oz. servings of protein for meals and 2 to 4 oz. servings for snacks of:

100% grass-fed beef, bison, pork, game or poultry  

100% grass-fed dairy, including eggs, cheese, yogurt, cottage cheese, milk, ice cream

wild-caught fish

organic nuts – ½ cup

Sacha Inchi powder – 1 serving

Complex carbohydrates – 7 servings of organic fruits and vegetables each day

A serving is an entire fruit such as an apple or a pear, or a cup of vegetables (peas) or fruit (strawberries.) It is ok to eat more than a serving.

Fats – Coconut oil (the more the better) for veggies and for frying; Moderate amounts of 100%grass-fed butter, ghee, or duck fat for cooking; Olive oil (limited amounts – use for salad dressings)

Grains – In general we do not need grains and most people do not do well with them, but 1 serving a day is ok if you are not intolerant or allergic. However, stick with these: 

  • Sourdough bread (2 slices)- the only bread to eat 
  • Hemp-seed florettes – high in protein and fiber, great rice & cereal substitute
  • Quinoa – some people cannot eat even this very ancient and relatively safe grain
  • Steel-cut gluten-free organic oats

Snacks – all fruits, humus and vegies, popcorn made with coconut oil, organic gluten free brownies, chocolate covered bananas or strawberries, apples and cashew butter, gluten-free crackers and cheese, raw or seasoned roasted nuts

This protein drink counts as a protein, a fruit and a vegetable on this plan. 

1 cup  plain 100% grass-fed yogurt

1 cup frozen blueberries

1 cup frozen peas or spinach

1 banana

1 cup pomegranate juice

½ cup cacoa

1 scoop sacha inchi powder or Dr. Axe collagen powder

¼ cup pre-biotic fiber

This drink has 76 grams of protein total and it makes 2 large servings (for 38 grams of protein each) or 3 small servings (for 28 grams of protein each).  In theory you could add another ¼ cup sacha inchi and if you made it into 2 servings it would be 50 grams of protein or 33 grams of protein for 3 servings. It is also loaded with pro-biotics, pre-biotics, fiber, antioxidants and vitamins

Weekly Tracking

Proteins     Fruits and Vegetables             Fats Grains

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Wednesday ____________________________________________________________

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Services Tab:

Change the tab CBT to DBT as follows:

What is DBT Training?

Dialectical Behavioral Therapy (DBT) was designed to help us regulate our emotions so that we can maintain our equilibrium.  We were “designed” to remain in a state of homeostasis. When something upsets this natural state the body compensates in some way, i.e. an infection causes a fever and overheating causes sweating.  

In much the same way, becoming very emotional drives us to compensate. Unfortunately, we often end up over-compensating. For example, we may overeat, restrict, binge and/or purge, over-drink or shut down emotionally in order to avoid emotional pain. This doesn’t work and as a result we end up suffering more than necessary and often creating new problems. 

DBT training was designed to enable us to reduce the level of arousal that we experience and therefore return us to homeostasis without the overcompensations tht end up becoming the problem.  We accomplish this by learning how to lean into the feeling instead of trying to avoid it or numb ourselves to it.  

The term ‘dialectical’ is derived from classical philosophy. It refers to a form of argument in which an assertion is first made about a particular issue (the ‘thesis’), the opposing position is then formulated (the ‘antithesis’) and finally a ‘synthesis’ is sought between the two extremes, embodying the valuable features of each position and resolving any contradictions between the two. 

“Truth” is seen as a pattern that develops over time in transactions between people, i.e. DBT is transactional in nature, or the result of human interactions. From this perspective there can be no statement representing absolute truth, as patterns are always changing and new truths are always emerging.  In a disagreement, from a dialectical perspective, truth is viewed as the middle way between two opposing points of view. 

The dialectical approach to understanding and treating human problems is therefore non-dogmatic, i.e. it is not restricted to a particular theory of pathology such as psychodynamic, gestalt or behavioral. Instead, the source of a problem, as well as its solution, is always open-ended and emerges over time as a result of a pattern, or patterns, of behavior. 

Another important assumption in systems theory is that problems are not necessarily linear in terms of what causes them. In other words, you may miss a lot if you believe that A causes B, i.e. molestation causes Anorexia.  Sometimes it is A plus B in the context of C&D that actually causes a problem, i.e. 

A. An unusually sensitive child; 

B. Overhears a negative comment about body fat; 

C. At a time when his/her body is changing because; 

D. She/He is going through puberty and reacts by restricting food which gets reinforced with weight loss and approval or concern from family and friends

In DBT Training there is always a balance between ‘acceptance’ on the one hand and ‘change’ on the other. DBT includes specific techniques of self-acceptance and self-validation that are designed to counteract the self-invalidation that many individuals with emotional problems experience. 

There are also problem-solving skills that act as a counterbalance to the acceptance skills. Finally, the therapy is mindful and behavioral in that, instead of regretting the past or dreading the future, it focuses is on the present moment.  We cannot change the past and we do not control the future, only our reactions in the moment.