Online Conference Transcript

Binge Eating / Compulsive Overeating with guest Joanna Poppink, MFCC

Joanna Poppink is has been treating adult women with eating disorders for over three decades. Her site, "Triumphant Journey: A Cyberguide To Stop Overeating and Recover from Eating Disorders" resides in the HealthyPlace Eating Disorders Community.

Bob M is the moderator.

People in Jersey are in the audience.

Bob M: Good evening everyone. I'm Bob McMillan, the moderator for tonight's conference. Welcome and I'm glad you could make it. Our topic tonight is Binge Eating/Compulsive Overeating. We're going to discuss some of the reasons behind it and then give you some concrete answers to the question of how you can overcome it...or deal with it. Our guest tonight is psychotherapist, Joanna Poppink, MFCC. Joanna has been in private practice in Los Angeles, California for nearly 18 years. In her practice, she has worked with many overeaters and helped them deal with the challenges they face because of their overeating. In addition, Joanna has written a guidebook of sorts, which is posted on the internet entitled: "Triumphant Journey: A Cyberguide to Stop Overeating and Recover From Eating Disorders". I'll be posting the URL for that later in the conference. Good evening Joanna and welcome to the Concerned Counseling website. I'd like to start off by having you describe some of your experience and work with overeaters.

Joanna Poppink: Hello Bob and all. I'm delighted to be with you tonight. Yes, I've been working with people who have eating disorders for many years. My work involves research, deep intimate work with individuals and also explorations into the community with a focus on 12 step programs. In addition, I am continually discovering that metaphors from biology and various sciences, coupled with dream work helps individuals get a closer appreciation and understanding of their own situation.

Bob M: I'm going to assume that people here tonight don't need to be told how to figure out if they are an overeater. But I'd like to know from you, excluding any physical ailment, like hyperthyroidism, etc., why do people overeat?

Joanna Poppink: The short answer to this complex and personal question is this: people overeat or binge because they are experiencing some kind of stress for which they have no tools or skills to handle. This does not, not, not, mean that overeaters or binge eaters have a personal deficiency. Often these people are extremely capable. However, somewhere in their history, they learned to cope with stress through food behaviors because they had no access to other methods of protection, adaptation or development.

Bob M: Are people who overeat readily aware that they aren't coping in a positive way with this stress, or for the most part, does it have to be pointed out to them?

Joanna Poppink: It's usually a mix. First, everyone who comes into therapy is in a different stage of their eating disorder. Some people have been binging and purging for a year or so. Others have been engaging in various eating disorder behaviors for as much as 25 or 35 years. So there is, as you can imagine, a tremendous range of awareness levels. However, while most do know that they use the binging to cope with their lives, they often do not appreciate the details. For example, many people with eating disorders are familiar with binging after a party at home when all the guests have left. Or they are familiar with binging after returning from a wonderful holiday. Certainly, they make assumptions about their binging after a sad, tense or painful experience. But they usually do not understand why they may binge after a happy experience.

Bob M: In your cyberguide to stop overeating, you speak of "essential equipment" that are necessary to be free of overeating. Could you elaborate on that, please?

Joanna Poppink: Yes. The development of an eating disorder serves a survival purpose. No matter how destructive overeating may be in a person's life, it is maintaining a level of existence that is tolerable, if barely (effects of binge eating). To begin to tamper with that balance, that system can release all kinds of surprising and disruptive feelings and actions. The inner equilibrium of the person is disturbed. This is necessary for healing, but it's a shock. So, in preparation for that, the person ready to undertake their healing journey can know this and gather essential equipment. Examples are a safe place to communicate either with self or a therapist or both. That means arranging for private time. Setting up a journal, scheduling walks, arranging for telephone contact with trusted people who can be told intimate details, going to 12 step meetings, all this creates tools that help with handling the emotions which will be released in change. Healing from overeating and binging is truly a courageous undertaking. People don't have to take on the challenge bare and alone. There is help and helpful equipment to use along the way.

Bob M: We are speaking with psychotherapist, Joanna Poppink, M.F.C.C., from Los Angeles, California. Joanna has done a lot of research on overeating treatment and works with many overeaters in her practice. She wrote an internet guidebook entitled "Triumphant Journey: A Cyberguide to Stop Overeating and Recover from Eating Disorders". A few other tools mentioned in Joanna's cyberguide include: being honest with yourself, accepting you don't know all the answers and that you will allow others to help, learning to recognize your own limits, gaining an appreciation that your binge eating has gone on for a while, it won't end overnight, and finally and very importantly, being kind to yourself. I'll be posting the cyberguide url later in the conference. Here are some audience questions Joanna:

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tennisme: This sounds so wonderful, but when things stop around us we still feel the inner torment. These feelings become intolerable so some of us go back to food or sometimes substances. What do you recommend when we are alone?

Joanna Poppink: Being alone and then alone with your thoughts, and especially, being alone with repetitive thoughts, is part of the healing challenge. The torment can be agony. I know. Binging is a way to get relief. Postponing for even a minute or 30 seconds can be a win. You get to find out that you can bear something a hairsbreadth longer than you thought. That can build strength if you are kind to yourself and appreciate your own efforts to heal and develop. And, journal, call a friend, call your therapist, call 12 step participants, go to a meeting, read poetry. One person I know said that going to a poetry book at 3:00 a.m. is like her soul dialing 911. And don't be hard on yourself for being in a difficult position. It's difficult to heal from overeating and binging.

JoO: Well -- you have said things that are very true. I have walked the walk and gone through various 12 step programs including AlAnon, ACOA, and Overeaters Anonymous. Each step along the way I received a bit more help. But it has taken ages. Now I am at the stage where I have to stop with the excuses...one of which is well people don't keep it off...etc. I think I have arrived at the point where I've almost put myself on self-destruct through weight and can't seem to stop the roller coaster. How do you get to the point where you say to yourself: "I have to do something and I'm going to do this now"?

Joanna Poppink: Sometimes you can hear the tone in your voice that comes from inner deeps and you know you must follow what you are saying to yourself. However, most of the time that voice is a critical voice that is more punishing than inspiring. So, I recommend that you approach the situation from an entirely different vantage point. Instead of pushing hard on losing weight, stopping eating behaviors, focus on expanding your perspective. Give yourself other kinds of nourishment. Read the classics. Take a class in something you know nothing about. Put yourself in a beginner's position somewhere and start. You might be surprised to discover how hungry your mind and your soul are and how enriching your experience is when you start to feed yourself properly. If you take an art class or a woodworking class or learn to repair your car, you might find that this activity is more interesting to you than binging and you might find that you put less time in the eating activities. This is not a cure. But it is a way to break established patterns including the pattern of being self-critical. Once a pattern is disrupted, there is room for something new to emerge. And maybe what emerges is the beginning of a new way of life for you.

Bob M: One of the things you mention in your cyberguide is that painful "secrets" people carry around with them relate to their overeating. What are you referring to and how did they develop?

Joanna Poppink: In my opinion, from my research, personal experience, clinical experience, private communications and more, painful secrets are the core of eating disorder development. I pause at the keys here because this is such vast territory. I'm searching for a simple example then can send you a picture.

Okay. Here's a simple one. A family is moving from one part of the country to another. The adults talk about how wonderful this move will be for everyone. They talk about how happy the 7-year-old child will be in the new environment. When the child shows any sign of fear, pain or loss, she is metaphorically "force fed" bright happy stories. This is not bad by itself. But if the child's genuine feelings are ignored and denied, the child will not learn how to live her way through her experience. She is learning that she cannot express herself, cannot find any validation for her experience, has to find a way to tolerate the agony of loss, i.e. friends, beloved teachers, perhaps pets, neighbors, familiar beloveds of all kinds. If it's too unbearable and too unacceptable for adults to hear, the child will try and often will successfully deny her own experience. So, she has a secret from herself that she is very angry, that she feels betrayed, that she is helpless, that she has no vote, that she must go along with the powers that be. She may start tripling up on chocolate chip cookies, but she will stop complaining. Later in life she may not remember this experience at all. Or she may remember it through the adults eyes and minimize her personal experience. She probably wouldn't have vocabulary to describe it. But she will notice that she finds it difficult to say no to someone in authority.

Perhaps she gives her authority away when it's not necessary. Perhaps she eats and smiles as she agrees verbally with someone (like a spouse or a boss or a leader of some kind) and inside she disagrees very much. This can be a description of an inner secret directing a person's actions, including binge eating actions. Getting back to the original story and, most of all, getting back to those original and genuine feelings from the past, working them through with honesty, can release a person from compelling and painful behaviors in the present.

Bob M: Here's some audience reaction:

Jersey: It can come from physical abuse, emotional abuse, conditional love, etc. early in life and many other reasons.

tennisme: It is difficult to heal and hard to live with your own failures. I start each day with a vow and ultimately feel emotionally terrible, binge eating and purge. I put off the urge, but it becomes inevitable. Are these secrets then like: child abuse, emotional neglect, poor self-esteem? Are you saying our inner emotions are neglected and misunderstood, so we don't trust our own instinctual feelings?

Joanna Poppink: I am saying we do trust our feelings, but we often don't understand them. Feelings are real. They can never be wrong. They are what we feel. We don't choose our feelings. However, we can misinterpret our feelings, judge them and ourselves and dig ourselves into a pit of depression. For example, tennis me writes about failures. I strongly question the use of the word "failure". Everyone one of us is a success just by making this far. Eating disorders, binge behavior, compulsive overeating are all coping mechanisms. They are survival tools. This is what has helped the person survive. This is not failure. This is success. The person is alive and sane. The problem is that there are more benign ways of caring for ourselves than eating disorders. So first, it helps to recognize that when you are binging or overeating, you are trying to take care of yourself in the ways you developed when this was the best you could come up with. The behavior is a clue, a signal, that something is going on that needs attention. It's not a failure. It's just using an old tool. When you start to respect that, you can become curious about exploring what other tools are available.

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Bob M:Someone asked me about the overeaters program Joanna mentioned earlier. That's "Overeaters Anonymous" and they have chapters in many cities around the country. You can look up their phone number in your local phone book, or go to one of the search engines and type in "Overeaters Anonymous" and go to their site for local chapter listings. I believe the program is free of charge.

Joanna Poppink: Overeaters Anonymous is free and I do recommend it. However, I recommend many 12 step programs, even if they are not directly about eating disorders. There is much to learn from other people's struggles and wins as they move to heal from compulsive behaviors of all kinds.

Bob M: Our guest is psychotherapist, Joanna Poppink, MFCC, who has researched and written about the topic. We have covered some of the reasons why people overeat and the things and "secrets" in their lives that keep them overeating (overeating causes). I think for many, Joanna, the underlying issues probably need to be dealt with in therapy. Do you think people can accomplish these things towards recovery on their own?

Joanna Poppink: Not being able to trust other people is part of the problem. So learning to trust others is part of the healing. That can't be done theoretically. Real flesh and blood people in genuine relationship are required. What form that takes can vary. I, from my vantage point as a psychotherapist, feel that psychotherapy is crucial. However, there may be other ways to develop on honest, trustworthy and deeply sharing relationship that will contribute to the person's healing. One major problem is that the binge eater, compulsive overeater, often has not learned how to choose trustworthy people. So learning how to recognize who is trustworthy, developing a posture where people have to earn trust, is part of healing. And this requires real people in real relationship.

Hero: I was fat as a baby. To my parents food was always the topic of conversation. I have had weight problems my entire life. I was never abused. Maybe overprotected? I am angry that food was so important when I was young (and still is). Will we be able to ever find out what is really making us overeat?

Joanna Poppink: Hero, sometimes parents overfeed their babies because it's their way of giving love. What then can happen, as it does to so many, is that food becomes an expression of love: e.g. chocolate for Valentine's Day, "sweets for the sweet", and there are many other examples in our culture. So a person may reach for food when they want love. There's soothing in the food itself. And there are associations of love from the past connected to the food. Food then has powerful drawing power when you feel insecure and needing love. Yes, we can find out what is making us overeat. Maybe not the precise details. But we don't need the precise details. We don't even need historical accuracy. What we do need is respect for our own processes. When we overeat, if we recognize that we are feeling something that we do not know how to accept, then we have the guiding tool to recovery. Then we can look in our lives, in our dreams, in our last conversation and try to find what it was that made us try to run away to oblivion for safety. Once we're on that path, there is no limit to the degree of healing and personal development we can achieve.

Bob M: One of our audience members, Sincerely, also mentioned to me that "when you are missing love, affection, or similar emotions, all the food in the world won't fill up that pot." I also want to touch on the subject of "dieting" here. When I use the term "dieting", I'm talking about a person who needs to lose 10-15 pounds, because they put on a little extra weight, for whatever reasons. But, I'm wondering Joanna, does "dieting", or diet programs, work for overeaters?

Joanna Poppink: It seems that all diets work and all diets fail. When we go on a weight reduction diet, if we stick to it for a few weeks or a few months, we will lose weight. When we lose that weight we lose some protective padding between us and the world. If we have not done the inner work to prepare us and to equip us to handle the world better, we will put that padding back on. Because our psyches now know that the original padding was not adequate (because we lost it), we will make adjustments in our inner formulas. We won't only regain the lost weight. We will gain extra for insurance. It's so important to remember that when diets fail, it is the diet that is failing, not the person. Diets can work for overeaters if the overeater addresses the issues that govern his or her eating. If and when she or he feels and is more powerful and able in addressing the challenges the world offers us, the padding is not as necessary. Then a diet can work. Although often, at that point, the person's weight goes down without dieting. Binging just isn't as interesting anymore. The person has more interesting things to do in life.

Bob M: Some more audience comments:

JoO: Some of us were brought up in the age where to seek help, or even to recognize the need, was shame-based. Emotional abuse, drunken parent you babysat and took the blame for his drinking, etc. So through 57 years, I have had to deal with this on my own because I couldn't 'allow myself' to feel.

Heavenly: exactly!!!!!! Is it best then to see a private therapist to work out problems before going to O.A.?

Joanna Poppink: Either way is fine. I do recommend that you see a therapist who is somewhat familiar with 12 step programs. In my work, I have recommended that people go to meetings. And people have come to me after being a participant in 12 step meetings. You can't really make a mistake here. The main thing is to begin. To JoO, not allowing yourself to feel is what eating disorders are all about. It's such a lonely place to be. And what makes it worse is when you do start to feel something and then criticize yourself for it. And that's part of eating disorders too. This is why I recommend that people go to all kinds of 12 step programs and listen. You will, at some point, hear someone tell your story, describe your feelings and show you how they are finding their way to a better life. Part of the nourishment needed in healing is valid, honest and trustworthy inspiration from real people. There are many people, including the people who participate on this site, who I'm certain, will applaud your allowing yourself to feel. Keep it up.

Bob M: As with everything, find a therapist that is good for you. If you are interested in 12-step programs, make sure you choose a therapist who is familiar with them. How? By calling around and asking them directly. 

Joanna Poppink: Thank you for having me. This was a pleasure.

Bob M: And to everyone in the audience, I hope tonight's conference was helpful. Remember, it's up to you to take the first steps and then follow through. Good Night.

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Dr. Keene: is our guest and he will be talking about Compulsive Overeating

Bob M: Good evening everyone. I'm Bob McMillan, moderator of tonight's conference. Thank you for visiting our website and chatrooms. Our guest tonight is a psychiatrist, eating disorders expert, and author of the book "Chocolate is My Krytonite: Feeding Your Feelings/How to Survive the Forces of Food". He's Dr. Matthew Keene. We'll be discussing why people binge/compulsively overeat and what you can do about it. And, in a few minutes, we'll open the floor for your personal questions for Dr. Keene. Good evening Dr. Keene and welcome to the Concerned Counseling website. Could you please tell us a bit more about your expertise and how you came to write this book?

Dr. Keene: Welcome to our guests. Hello everyone. I went to medical school at Georgetown University, trained at the Cleveland Clinic and am board certified in psychiatry/neurology and addiction psychiatry. My first job out of medical school was working with compulsive overeaters. It has been so rewarding that I have continued my work.

Bob M: You've done a lot of research on the subject of compulsive overeating. What are the most important factors that lead someone to binge eat?

Dr. Keene: I think it is a combination of the genes God gave you combined with poor feelings management.

Bob M: Can you explain what you mean by "poor feelings management"?

Dr. Keene: I am not using the word "poor" as a derogatory term. I think we are conditioned from birth to associate food with comfort. Think about it...as infants the only way we could express ourselves was to cry. What we really wanted was mom and dad to comfort us. But they always brought that secret weapon, formula. We will talk later, how formula and more importantly, other processed carbos, can alter the physiology of a compulsive overeater. For now, it is important to understand that compulsive overeaters often use food to deal with uncomfortable emotions. Our goal is to teach them healthier ways of expression.

Bob M: You mentioned genetic factors and some psychological issues, can a person be simply "addicted" to food?

Dr. Keene: That is exactly what I am saying!!! It has been estimated that 18 million Americans are addicted to the most powerful drug known to man....food. Certain foods, like any other addictive substance, can powerfully alter body chemistry in certain people. The chemical that is of importance in this process is Serotonin.

Bob M: Just to clarify for everyone here, what is Serotonin and what role does it play in our body chemistry?

Dr. Keene: Serotonin is our happy juice. Or more technically, it is a brain chemical that creates a feeling of satisfaction. Not just emotional satisfaction, but physical as well. As it turns out, compulsive overeaters have been found to have Serotonin levels that are 4 times lower than normal. So if your happy juice isn't at the right level, you have a tendency to feel depressed, irritable, anxious etc. Our bodies are pretty sophisticated and can sense this. But it is not like it can tell you to go to the Jiffy Lube and say you're a quart low of Serotoin. Instead, it looks for other methods....food, alcohol, etc. In fact, just two slices of bread with jelly can boost Serotonin by 450%. Imagine what an entire binge can do.

Bob M: For those of you just coming in...welcome. We're discussing the causes of Compulsive Overeating/Bingeing and what can be done in terms of treatment for. Our guest is Dr. Matthew Keene, psychiatrist, eating disorders expert and author of the book "Chocolate is My Kryptonite: Feeding your Feelings/How to Survive the Forces of Food." Two things I want to make sure we all understand: 1) Are you saying, yes there are psychological factors leading to compulsive overeating, but an overeater's Serotonin levels are the major cause of overeating? 2) If we fix the serotonin levels, will that be the main answer towards making a significant recovery?

Dr. Keene: Not necessarily. Stabilizing Serotonin is essential to recovery, but if you continue to have a psychological mindset to use food as a coping tool, recovery will remain elusive. That is why it is important to address both biology and psychology for any long-term recovery.

Bob M: One last question from me, then onto some audience questions. Can a person make a "full recovery" from compulsive overeating"?

Dr. Keene: Absolutely! The disease of compulsive overeating can't necessarily be cured, but it can be put into complete remission.

Bob M: Here are some audience questions:

Mer512: I know what I am doing when I start a binge. I know how I will feel afterwards and yet I don't stop myself. I know that I am comforting myself and temporarily it works, but I also know how I will hate myself later and yet I do it. Should I just give up?

Dr. Keene: Of course not. All of the feelings that you are describing can be dealt with in time and with proper treatment. It is normal to feel out of control when the bingeing is out of control. But when you begin to understand the disease and how to eat properly, combined with improved feelings management, success is at hand.

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Bob M: As we proceed through the conference tonight, Dr. Keene is going to give us a "meal plan for the rest of your life". Here's the next question:

Flyaway: Are there certain categories of food that contribute more to a boost in the Serotonin level?

Dr. Keene: Absolutely! All processed carbs, including bread and pasta, will give a temporary boost in serotonin, but the key word is "temporary". The boost lasts an hour or so. Then comes the calories, the weight gain, the guilt, and shame, and worse still, serotonin levels plunge downward, even further than before you ate the carbs. So in the long run, if not treated, binge eating becomes progressively worse.

Sue MR: So no more carbs?

Dr. Keene: No. Whole complex carbs are the most important treatment to overcoming overeating (binge eating treatment). It is the processed carbs that are deadly. Take a look at alcohol. We would all agree it is addictive. But what is alcohol, but the ultimate processed carb. It is liquid sugar with a kick!! For some compulsive overeaters, sugar, bread, junk food, etc. can be just as addictive. Unfortunately, society is yet to recognize this.

turtle31: What can be done about the Serotonin levels? What specific foods are high in it?

Dr. Keene: The solution is not to eat foods that boost serotonin through the roof, but instead eat foods that will create stable serotonin levels throughout the day. We do this by combining the right amount of lean protein with whole complex carbs. These foods will stabilize Serotonin. As importantly, since whole foods take longer to digest, you feel full longer and crave less. Finally, you begin to fill up on vitamins and minerals and bran instead of empty calories.

Bob M: Some examples of whole complex carbs, please.

Dr. Keene: Good question. Just about everything that God gave us. Fruits, veggies, whole grain, etc. Unfortunately, we live in a society that has processed our foods beyond recognition. So initially it seems difficult to obtain high-quality food. But when you realize that to treat this disease effectively that it doesn't require rocket science, but a return to basics, it is actually quite easy to treat.

Bob M:I received a couple of messages on Dr. Keene's book. It's called "Chocolate is My Kyptonite". Dr. Keene, before we continue on, there are also some audience questions on what exactly constitutes "compulsive overeating". How much food do you have to take in, and in what frequency, to be considered a "compulsive overeater"?

Dr. Keene: There are diagnostic criteria that professionals use to identify compulsive overeating (compulsive eating symptoms). Unfortunately, it is almost too easy to meet the diagnosis. You just have to answer "yes" to these 3 questions:

1. Do you eat large amounts of food in a short period of time?
2. Do you have trouble stopping at one bite?
3. Does this happen twice or more per week?

I think in the '90s, we would all meet this. That is why I include the following two points.

1. Do you crave processed carbs? I think this is imperative to accurately pinpoint those who may have a serotonin deficiency.
2. Is overeating causing you some sort of physical, emotional, or social harm?

I don't think it is fair to diagnose someone with an eating disorder if there are no recognizable consequences.

Bes: I feel like I can't control my eating because I always feel hungry. How can I stop feeling hungry?

Dr. Keene: Again, Serotonin is our satisfaction chemical. Until you are able to stabilize Serotonin, you will likely to continue to feel hungry. The "Menu for Life Plan" outlined in the book is one way to stabilize Serotonin. But there are others as well. For example, people who exercise have 50% more available Serotonin than couch potatoes, and I am not talking marathon running or step aerobics. Somehow, we have become convinced that loud music and lycra burn calories. It doesn't. A simple walking program is a great start.

Bob M: Don't worry, we are not going to let you leave tonight before giving us a few parts of the menu plan. :) Here are a few audience comments, some reaction to what's being said:

Kim4: I don't feel like I eat because of "hunger"...that makes it even harder to stop the binge!!

Stever: But boy, fruits have so many fat calories in the glucose. I hate to eat too many of them. I'd rather just not eat anything at all.

mulan: Dr. Keene - bread? I don't think Dr. Judith Wurthman will agree with this either.

Dr. Keene: Let me respond to a few of the comments. Fruits contain fructose not glucose, and fructose does not have the same derogatory effect on serotonin as does glucose. Next, you are right. Bread may not be unhealthy for all compulsive overeaters though. It is important to identify your own personal trigger foods.

cricket: If these foods give a boost, then why after eating them do I feel very tired. It can affect me in as little as 15 minutes, and I become incredibly sleepy.

Dr. Keene: Serotonin is a calming chemical. Any foods that artificially boost it too high can make you feel too calm, i.e. sleepy.

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OceanFree: I usually go for periods of time when I don't eat. I went through a few months that I was a compulsive eater and I gained about 20 lbs. What could be the reason for the drastic change in the eating pattern?

Dr. Keene: Compulsive overeating like many illnesses will wax and wane. It is not uncommon to go weeks or months without bingeing only to return to the binge cycle when either your physiology or your stressors change.

turtle31: Then what can we do to prevent reoccurrences?

Dr. Keene: Relapse is a part of any addiction. It is important not to beat yourself up if a relapse occurs. I think that the "one day at a time" approach that overeaters anonymous uses makes good sense. But sometimes it has to be more than one day at a time. It has to be one meal at a time.

Bob M: Do antidepressants work in helping treat compulsive overeating? Or any other medications for that matter?

Dr. Keene: Great question. I really believe that changing your eating habits, combined with improved feeling management can help the majority of compulsive overeaters. But like any other disease, once you have exhausted the conservative approach, medication can be useful. Antidepressants that stabilize serotonin are helpful only if you target the right person with the right dose. In these cases, proper use can result in significant and sustained improvement. The key is, not to necessarily target weight, but to target bingeing.

Bob M: And some specific names of these medications that might prove helpful?

Dr. Keene: Where do I begin? Medicines like Phen-Fen and Meridia boost serotonin, but at the expense of significant risk. Herbal medicines like St. Johns Wort and 5HTP are reported to boost serotonin, but there aren't any good and true scientific studies to support this. Although I do have several patients who report good results with herbal meds. So that leaves us with the only medicines that have actually been studied to reduce binge eating: Prozac and Paxil (throw fruits and vegetables at me, if you wish). But if you target the right person and not try and use a "one size fits all" approach, people treated with these medicines will have great success.

BC: What do you think about the nondieting approach? After years of restricting and binging, will eating "normally" (i.e. eating when you are physically hungry, stopping when you are full) help to boost your metabolism and stabilize your weight?

Dr. Keene: They will for some people, but others may need to subscribe to more of an abstinence model. The key is not to let anyone, including me, lump you into one approach. I think there is an "ideal" and a "real" abstinence. If you try and follow a completely abstinent food plan, you will have great difficulty succeeding. Some can do it, but quite frankly most can't. That is why I think it is important that everyone develops a list of their own personal trigger foods. That is, foods that invariably lead to a binge. Focus your attention on refraining from these foods and success becomes a whole lot easier.

Bob M: I also want to ask about another program that suggests: if you are a compulsive overeater, then bring all the foods you love and crave into the house and eat as much as you want. Eventually, the theory goes, you will become so tired of them, they won't attract you anymore and that's when you begin to control your compulsions. What do you think of that?

Dr. Keene: To me that is like giving a cocaine addict all the crack that he/she wants and expecting them to improve. That type of treatment, flooding or implosion, works well with anxiety disorders, not with addiction/compulsive overeating.

Diana: Is there any time schedule to putting compulsive overeating in "remission"?

Dr. Keene: Most studies suggest that it takes upwards of 6 months for the behavioral and physiologic changes to take root.

Bob M: I promised everyone we'd get to this. Can you please give us your "food plan for the rest of our lives"?

Dr. Keene: Obviously I can't provide a diagram of the food plan via the chatroom. So, here are the basics:

Bob M: As Dr. Keene is answering that, his book is entitled Chocolate is My Kryptonite.

Dr. Keene: 4 meals per day...(as our body will maintain peak metabolic efficiency if it has food about every 5 hours). Each meal combines the right amount of protein with complex carbs to best stabilize serotonin. The "meal plan for life" is divided into two phases: a weight-loss phase and a maintenance phase. In the weight-loss phase, caloric intake is low enough that people will lose 6-12 lbs. per month. But, since it emphasizes whole foods, people can lose weight without craving or suffering. It also has additional health benefits such as lowered cholesterol, improved mood, improved sugar balance. It is actually a very good food plan for diabetics according to our endocrinologist.

SueMR: My doc believes in "metabolic fitness". If your blood sugar and cholesterol are normal, then one shouldn't worry too much about the weight.

Dr. Keene: That is true if you are physically healthy. But if binge eating is causing social or emotional problems, then perfect health isn't so grand.

Bry: I've been told lowering calories can be problematic in that it fools the body into thinking its starving and messes up the serotonin levels.

Dr. Keene: If you lower the calories too much, like I believe the Atkins plan does, you are absolutely right. In fact, food plans that are too protein heavy, even if they are low in calories, will actually lower serotonin.

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Dr.Tucker-Ladd: How do you teach "feeling management"?

Dr. Keene: It is a combination of improving coping skills through teaching increased expressiveness, assertiveness, boosting body image, and lifting self-esteem. And I think there are a number of self-help books, including mine, which can teach you these skills without necessarily going through intensive psychotherapy. However, many compulsive overeaters may have some deeply rooted issues, such as sexual abuse, that require individual therapy.

willowbear: Bob, did Dr. Keene talk about taking serotonin supplements? I see them in the health food stores all the time. Are they for real or a rip-off?

Dr. Keene: Nobody knows for sure yet. I assume you are referring to the herbal remedies offered. As I have said, some of my patients swear by St. John's Wort, while others wouldn't touch it with a ten-foot pole. There is good data to support St. John's Wort for treating depression, but not a single study has looked at whether it works for eating disorders.

Bob M: What about diet pills? Are they ever useful when it comes to compulsive overeating?

Dr. Keene: I don't think so. Diet pills treat a symptom, weight, not the disease.

Marsh: I've heard the meds only have a short term effect on the binging. What is your opinion?

Dr. Keene: Medicines have a short term effect in promoting weight loss. They appear to work better towards eliminating binge episodes. But again, you need to treat the right person with the right medicine and not assume that everyone needs pills to treat a disease that can often be treated with better feelings and better feeding.

Bob M: We have many people who visit our site, who go from eating disorder to eating disorder. From anorexia to bulimia, onto compulsive overeating and back again or in combination. We are constantly being told, diets and weight loss programs are one of the key ingredients to the start of an eating disorder. Should someone who's been an overeater for a long time be concerned that by going on a "program," it could lead to anorexia or bulimia?

Dr. Keene: Let me answer this in several parts. Firstly, I think bulimia is often an evolution of compulsive overeating. Compulsive overeaters gain more and more weight until purging seems like a viable alternative. The same serotonin defects that exist in compulsive overeaters also exist in bulimics. I think true anorexia likely affects a different part of the brain. There is a condition known as bulexeremia that is best treated by combining treatment approaches for both anorexia and bulimia. I agree that diets and society's notion that rail-thin beauty is the cultural ideal contributes to all eating disorders. That's why I prefer treating compulsive overeating as a disease with a meal plan for life versus diets which have a 98% failure.

wasted: Are serotonin levels different in anorexics as opposed to binge eaters?

Dr. Keene: Yes, anorexia really is a much more neurologically, chemically, as well as emotionally complicated illness.

Bry: You mentioned your eating program. It takes energy and commitment. How does one with binge eating get to the point that they can follow a program?

Dr. Keene:I think like any addiction, people need to get to the point in their life where making a major lifestyle change seems to be a priority. This is obviously a very personal matter. I think it is important to mention again the issue of relapses. Success is almost always preceded by failed attempts. In other words, to be a bit cliché..if at first you don't succeed...etc etc.

Bob M:I want to thank Dr. Keene for being our guest tonight and for staying late to answer extra questions. It's entitled "Chocolate is My Kryptonite: Feeding your Feelings/How to Survive the Forces of Food". Thank you again Dr. Keene and to everyone in the audience for coming tonight.

Dr. Keene: Thank you for having me.

Kim4: Please express my "thanks" to Dr. Keene...it was great!

willowbear: Thank you Dr.Keene. It was very informative!!!! thanks, Bob

Flyaway: Bob, thank you for this conference. It was very good. Thank you very much for your helpful information, Dr. Keene

Bob M: Good Night

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Transcript from Online Conference with: Dr. Steven Crawford on Compulsive Overeating

Bob M: Good evening everyone. Our topic tonight is "Compulsive Overeating". Our guest is Dr. Steve Crawford, Associate Director of the Center for Eating Disorders at St. Joseph's Medical Center. Good evening Dr. Crawford and welcome to the Concerned Counseling website. I'd like to start off by having you tell us a bit more about your expertise.

Dr. Crawford: Good evening, Bob. I have worked with patients with eating disorders for ten years. I currently manage the inpatient and day treatment programs at the Center for Eating Disorders and assist patients with initial consultations to design an individualized treatment plan.

Bob M: Can you explain the difference between compulsive overeating and obesity?

Dr. Crawford: Obesity is a medical term. It simply means being more than 20% above the upper limit for age and height. Compulsive overeating is a behavior. It refers to a pattern of eating that is frequent and usually in response to uncomfortable emotions. It is similar to other eating disorders such as anorexia nervosa, bulimia nervosa and binge eating disorder.

Bob M: How does one figure out if their eating patterns have become a problem...in terms of binge eating?

Dr. Crawford: People that binge eat are usually aware that their eating pattern is a problem. They experience extreme feelings of embarrassment, guilt and depression with their eating. Binge eating disorder is when someone is binge eating at least two days per week for 6 months. It is different from bulimia in that patients do not attempt to counteract the effects of the binge eating...that is they do not induce vomiting, use laxatives, compulsively exercise etc.

Bob M: How does one change the behaviors then that are associated with compulsive overeating?

Dr. Crawford: It is helpful for individuals to begin to identify their particular "triggers', that is events in their life that usually result in them binge eating. Once identified people can begin to work on new ways to deal with these triggers or stress.

Bob M: When you say "triggers", what kinds of things can initiate binge eating?

Dr. Crawford: Trigger generally refer to events that the person experiences as stressful. These can be both positive and negative. Examples are: doing poorly on a test, having problems at work, or getting a promotion. Day to day events such as rush hour can also be a trigger. In working with patients, we try to help them begin to differentiate between physical, real, hunger and emotional hunger.

Bob M: What then are the most effective treatments for binge eating?

Dr. Crawford: Treatment for binge eating disorder consists of several components: We provide patients with nutritional counseling to begin to understand their eating pattern and work towards healthy eating patterns. Therapy is also an important component, both with group and individual therapy. Groups help patients to not feel so isolated and begin to work on self-acceptance. Individual therapy allows patients to explore the use of food for psychological stress. Also, we evaluate if any of the antidepressants would be beneficial in decreasing the impulses to binge eat.

Bob M: Is the treatment done on an inpatient or outpatient basis, for the most part?

Dr. Crawford: Generally treatment for this population is done on an outpatient basis. Patients may get admitted to the inpatient or day treatment unit if they have a severe depression or they have medical problems that are in need of immediate attention.

Bob M: Besides the anti-depressants, are there any other medications that are being used or are on the horizon to control binge eating?

Dr. Crawford: There are currently a host of new diet pills that are now being marketed or are on the horizon. The newest agent is Meridia. This medication, however, is not one that I consider to be known to be effective over the long term and its safety is questionable. 4 out of 5 of the FDA advisory board members actually voted against having Meridia approved. It was allowed on the market because of the demand for these drugs. Meridia is known to cause elevation of blood pressure.

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

frcnb: How can diet pills be helpful to those who eat when not hungry?

Dr. Crawford: I do not think diet pills are helpful. They are temporary solutions that do not work long term. It is more helpful for individuals to learn coping mechanisms that will allow them to not eat when they are not hungry.

withattitud2: How common is it that one binges, then follows with starvation patterns?

Dr. Crawford: This is not uncommon. People frequently feel uncomfortable after binge eating. They can feel extremely guilty and attempt fasting. This actually is considered to be more of a bulimic pattern than just binge eating.

Bob M: For those just joining us, our guest is Dr. Steve Crawford, of the Center for Eating Disorders at St. Joseph's Medical Center. We are talking about compulsive overeating and taking questions from the audience.

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Diana: Can you give examples of coping mechanisms?

Dr. Crawford: Coping mechanisms are ways to try to reduce stress and to feel more comfortable. They are very individualized. We try to help patients identify ways that they can take care of themselves. Stress management with breathing exercises can be helpful. Learning to go for a walk or call a friend can be useful alternatives to binge eating.

Bob M: For many who binge eat, Dr. Crawford, they tell me it satisfies an emotional need, but then they feel bad about doing it. What specifically can be done to break that cycle? And secondly, is the treatment currently available for binge eaters a long-lasting one or are there relapses?

Dr. Crawford: Breaking the cycle does not occur overnight. One does not make an immediate change to longstanding patterns of behavior. The breaking of the cycle is more of a gradual process with the individual learning over time how to replace the binge eating with other behaviors. Do not expect immediate results or you will be greatly disappointed. Developing control over binge eating is a long term process. Results can be long term as well as the person begins to make life changes. Usually the person does need to be constantly on guard of falling back into old familiar and yet destructive patterns of behavior.

Nicoliz: What's the best way to cope with extremely strong cravings which usually lead me into a binge?

Dr. Crawford: When cravings are overwhelming the person usually does not have time to think clearly. We try to have individuals make a list of alternative behaviors so that in the moment of a craving they can refer to the list to identify alternatives to binge eating. At times medications are necessary to decrease the intensity of the binge impulse. These medications are the antidepressants such as Prozac, Paxil, etc.

froggle08: When I binge eat, going for a walk or calling a friend doesn't help. I could be with my friends or out walking, and all I want to do is go home and eat. What else could I do?

Dr. Crawford: Generally the longer one is able to stall acting on the impulse, the more likely they will be able to not binge eat. Frequently patients tell me that after a certain period of time, the impulse begins to subside. That is why I recommend attempting to distract oneself when they first get the impulse. If you end up acting on the impulse and binge-eating, the important thing is to remember that it does not have to continue. We also try to help people work on stopping the binge process after it has started. Learning to recognize when one is binge eating and then stopping it midstream is an important step in recovery.

Gemma: So, for someone who doesn't have good support around them - what could be their first step to recovery?

Dr. Crawford: Recognizing the problem and then seeking support. Support groups can be extremely helpful. Also seeking professional binge eating treatment if the problem feels out of control.

JoO: I am EXTREMELY overweight -- I lived with emotional abuse as a child and shame wouldn't allow psychological help. I didn't even know it existed. I've gone through different support groups -- each helped heal a little of the pain and the things I didn't understand. I have now spent years trying to help myself through this route. I believe I had to 'go through the pain' in order to heal. But isn't there an easier way? Would help dealing with the emotions have made me heal a lot faster? And even though I think I have dealt with the emotional pain, I'm still overweight. What can I do now?

Dr. Crawford: We believe that there are two important components to treatment, changing the behavior is one and understanding what is driving the behavior is the second. Both components are equally important. If you have been at an above normal body weight for an extended period of time, your set point may be high. Working towards size and self-acceptance are important at this time for you. Dieting is the worse answer. It will set you up to feel disappointed repeatedly.

JoO: This is fine and I agree with you. I have had to learn to see some self-worth in myself. However, I can't stay like this forever. So what would be the next step? My health and sanity demand that this cycle be stopped.

Dr. Crawford: The next step is working towards not binge eating. This is done by not attempting to diet, but to normalize the eating pattern with three meals and a snack per day. Many binge eaters do not have a normal sized breakfast. This results in increased hunger and causes the person to be more likely to binge later in the day.

Bob M: So, is it possible then for a binge eater to do self-help or does it require working with a therapist to be really effective and long-lasting?

Dr. Crawford: Self-help is possible. If the problem has been longstanding and a way of life, frequently nutritional counseling and therapy are necessary for you to begin to understand the binge eating and its psychological component and make life changes.

Bob M: Besides compulsive overeating, there are people who do what's called "grazing". Can you distinguish between the two, please?

Dr. Crawford: Binge eating is defined as eating large quantities of food in a relatively short period of time, usually 2 hours or less. During this time the individual feels a sense of loss of control over their eating. Grazing is a pattern of behavior of eating throughout the entire day. It is less frenzied and more a constant picking at available food. People that graze frequently, keep food in the car, at a drawer at work, or in their bedroom.

Bob M: And is their thought pattern different...in that they don't believe it's as bad as overeating?

Dr. Crawford: People that graze frequently do not count what they have eaten between meals. When describing their eating over a day, they will review their meals and leave out the food in between. This is usually because they tend to not be aware of what or how much they have eaten between meals. This is very different from the person who binge eats and is very aware of feeling out of control.

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Lynk: I don't starve myself. I just keep eating and eating. Is this usual?

Dr. Crawford: Binge eating disorder is defined as not counteracting the effects of eating large quantities of food. Most people that binge eat, do not starve, but repeat the pattern of binge eating over and over.

Gemma: Is there a difference between people that overeat and those that stop eating? Are the emotions behind the behavior generally the same?

Dr. Crawford: I believe that there are great similarities in the two problems with people using food in very different ways to cope.

Bob M: If one were to be serious about recovery, and really dedicate themselves to it, how long would it take before you start to see results?

Dr. Crawford: Again results come gradually with progress met at times with setbacks. We try to assist people in first not looking at the scale to judge if they are making progress. We try to define progress as movement towards a healthy lifestyle with normalized eating patterns and increased activity. Movement can begin as early as the first session.

Bob M: Is there such a thing as people who compulsively eat and then vomit?

Dr. Crawford: While this is not a defined category, there are many individuals that do engage in this process... that is, they do not binge but will induce vomiting after eating normal sized meals. These fit into an unspecified category, but still have an eating disorder that deserves attention and treatment.

Bob M: Previously, we had a guest on, and I know there's a new book out on this, who spoke about the theory that you can just eat everything in site, until finally you are repulsed by food and quit eating and settle into a comfortable and more healthy eating pattern. Is this realistic? And is it healthy? And is it effective?

Dr. Crawford: Frequently, people are accustomed to a diet mentality and are used to depriving themselves of food that they want. The concept behind this theory is that by allowing oneself to eat what they want, when they want it, it will decrease the desirability of that food and decrease the likelihood of bingeing. It works on the premise that as humans we want what we cannot have or at least what we are told we should not have. This gives it greater importance. By permitting oneself to eat, it becomes a part of everyday life. This is slightly different than the idea you suggest with eating until you are actually repulsed by food. This would not be healthy in that it is important to learn to incorporate food into your life in a healthy way.

Bob M: Here's an audience comment on that:

frcnb: I'm afraid I couldn't stop once I started.

Dr. Crawford: In summary, eating until you are actually repulsed by food is probably not helpful but allowing oneself to eat what one wants when wanted is helpful.

Bob M: It's getting late. I appreciate you coming tonight Dr. Crawford. And thanks to everyone in the audience. 

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

Bob M: Good Night.

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Bob M: Good evening everyone. Thanks for coming tonight. We have an excellent guest tonight and a topic we don't ordinarily discuss too much under the category of eating disorders. That's overeating. In case you haven't noticed, we opened an overeaters room in our chatrooms about a month ago as more and more people with interest in that started coming to our site. Our guest tonight is Jacki Barineau. Jackie is one of the Program Directors of "Overcoming Overeating." The philosophy is based on a book by that same name by Jane Hirschmann and Carol Munter---two psychotherapists. Although Jane couldn't make it tonight because of previous commitments, she highly recommended Jackie and so we are glad to have her here tonight. Good evening Jackie and welcome to the Concerned Counseling website. Could you start off by explaining the philosophy of Overcoming Overeating.

Jacki Barineau: Thanks for inviting me Bob and good evening everyone. The O.O. approach is basically a "non-diet" approach to ending compulsive eating problems. It is based on the premise that dieting CAUSES compulsive eating and weight gain and that by ending dieting and body hatred we can cure the compulsive eating.

Bob M: And that is one of the premises of the program and it's a common one with all eating disorders--that of people disliking their own bodies. How does the "Overcoming Overeating" program address that?

Jacki Barineau: First, we have to decide to let go of the idea of changing our bodies - they may change, they may not. But we choose to accept them just as they are now and let go of "society's" standards of beauty. We clean our closets of all clothes that don't fit or that we don't like. We start dressing ourselves with care and like we're wonderful just the way we are.

Bob M: Now when you talk about compulsive overeating, can you define that for us please Jackie?

Jacki Barineau: As a former compulsive overeater, I can say that for me it meant major food binges that were uncontrollable. The eating had taken over my life and I was drowning in self-hatred. It is being totally unable to stop binging even though you desperately want to stop.

Bob M: And what was it that made you take "action" to change this compulsion?

Jacki Barineau: Many things. Of course I dieted for 25 years (age 7 to 32) - tried Overeater's Anonymous. I felt like a failure. Finally, I was so sick of dieting and worrying about my weight and being obsessed with food, that when I found the "O.O." book I was SO ready to let go of all that. I figured I'd done everything else and was only more and more obsessed and compulsive that maybe trying something totally opposite might be the answer - and it was!

Bob M: Just so everyone can see, here are the building blocks of "O.O.": 1. compulsive eating may seem self-destructive, but it is always an attempt at self-help; 2) Diets never, never solve eating and weight problems. Diets CAUSE compulsive eating; 3) Significant change flows only from self-acceptance; 4) Food is not the compulsive eater's problem, it is the solution. I have read your story Jackie, but I would like you to tell the audience some details of when and why you started putting on weight and your height and weight that you had progressed to?

Jacki Barineau: My problem started at age 7 when I was put on my first diet by my parents. I wasn't even overweight! But that diet began a lifelong battle because it triggered the inevitable binge that dieting always causes. This also led to true weight gain. Then the yo-yo dieting through the years caused more and more weight gain. I dieted my way up to over 250 lbs. (I'm 5'4") before finding "O.O."

Bob M: Now, when you say "O.O.'s" theory is eating your way out of your eating problem, what specifically does that mean?

Jacki Barineau: We "legalize" all foods. It's human nature to crave what's "forbidden". This is why dieting leads to binging. By making ALL foods "okay" and "equal" (in our minds), we no longer will have uncontrollable urges to binge on "forbidden foods". Chocolate = lettuce = cookies, etc. Then we go back to our original way of eating - demand feeding (the way babies are fed). We learn to reconnect our eating with our physical hunger signals. Dieting has destroyed that connection for most of us.

Bob M: So what you are saying is...."O.O." is not going out and drinking powered milkshakes and buying food plans, etc., but really changing your psychological makeup by accepting yourself for who you are and quit trying to be what "Hollywood" wants you to be. It's reconnecting food with hunger rather than trying to fill some psychological need. Am I correct in that?

Jacki Barineau: Exactly! Except that we don't try to stop ourselves from eating for psychological reasons as if that were a "bad" thing. We don't "stop" eating from "mouth hunger," rather we "start" eating from stomach hunger. A very different perspective.

Bob M: Here are some audience questions Jackie...

Netta: Okay, I tell myself that Ben and Jerry's is legal and equal to any other food. How do I stop at a little of it instead of eating the whole carton?

Jacki Barineau: Good question! Everyone assumes that if they legalize these kinds of foods, they'll never quit eating them. In reality, once you're convinced you can have them whenever you want them, you no longer will want so much of them. At first, you will probably need to eat lots to convince yourself it's okay. The key is to NOT "yell" at yourself. We say don't buy just one. Buy way more than you can possibly eat in one sitting. Abundance really helps you to calm down and knowing the food is there whenever you want it, reassures you that you don't have to "eat it ALL" now!

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Bob M: It's the theory of "you want what you can't have." But once you have it, it's no longer that desirable. Here are some questions Jackie:

cw: How do we 'let go" of society's standards, when society regards us with contempt at every turn? Isn't that like telling devastated children to "ignore" kids that beat them up at school?

Jacki Barineau: Exactly. I think it's important to not allow society to dictate how we (or our children) feel about ourselves. It's not easy, but by living our lives fully in the "present" and accepting that nobody has to be the same size, we can start to change how we feel. A good question to ask is: "Who says one thigh size is better than another?"!

cw: What do we do with the justifiable hurt and anger that results from being rejected by society as a result of their standards?

Jacki Barineau: By making a conscious decision to "buck the system and regaining our self-respect, we can then make peace with our bodies. Eventually, we come to the point, we no longer care what "society" says. It has to come from within. The hurt and anger diminish as we learn to love ourselves.

Bob M: To put it another way, no matter who you are, black, white, skinny, heavy, rich, poor, there are going to be people who like and dislike you, for whatever reason. But that doesn't mean "that's who you are".

cw: I can see where 'bucking the system' would make the future better, but you talk about living in the present, which hurts. How do we do that?

Jacki Barineau: "Bucking the system" also helps us in the present. It's very emotionally satisfying to come to terms with yourself and your life, exactly as they are. As far as present hurtful things, all I can say is that nothing can hurt us unless we allow it to. We can "choose" to think and act differently. By being "true to ourselves", no one else can have power over us.

Bob M: And also, I want to make a comment here, you have to look inside your own life and see why you used food the way you do/did? What need did it fill? Just referring back, for a moment to the previous question and answer about getting more than you want, and please be honest, were you worried about putting on more weight? Did you put on more weight, at least when you started that?

Jacki Barineau: Honestly, I was so tired of my whole life being about my body size and about dieting/binging, I didn't CARE. I was so happy to be free from the compulsion, if I never lost another pound, I was still better off. I did gain a little (20 lbs.?) at first, but I would have probably gained more if it hadn't been for O.O..because I was coming off a diet and was in the "binge" part. O.O. has STOPPED the weight gain now and this is so worth it to me.

Miktwo: As I gained the weight I became more depressed, which made me eat more. How do you deal with the depression while you are making the change or taking the action?

Jacki Barineau: Tough one. What I did was to constantly do things that made me feel cared for. We learn to nurture ourselves in new ways. I also used lots of positive self-talk" and treated myself with kindness. By taking these "actions", the "belief" eventually comes.

Bob M: What do you mean by "treating yourself with kindness"?

Jacki Barineau: I worked really hard at NOT yelling at myself or saying unkind things about myself. I wouldn't treat a friend that way! I started treating myself like I would a good friend. I bought nice clothes and "owned" my own closet (who WERE all those other clothes for anyway?!) I started demand feeding, which is VERY emotionally satisfying. It makes you feel your needs can be met.

Bob M: By the way Jackie, because I'm getting some comments from the audience, at 5'4", how much do you weigh now and are you "psychologically comfortable" at that weight?

Jacki Barineau: I no longer weigh myself (my weight is not my business anymore!). However, I'm still a large person. Yes, I feel better about myself now than even when I was down to 150 after a diet! Self-acceptance can come at any size :)

Bob M: Here's an audience comment, then a question:

Echogram: Yes, I've been able to lose weight once I quit dieting Also, I allow myself to have any food I want and now I find I am making better choices and I bought a treadmill and walk on it every and was able to lose inches too.

JoO: If we just 'be' and take the worry out of it, it probably would just happen. Jackie, you are documenting my life. I know if I could do this, I would probably lose weight. But with diabetes and mega-health problems. How does one go about it?

Jacki Barineau: I also have diabetes. I can only say that for me, if I were to make certain foods "off limits", even for "health" reasons, I would end up binging - which would only make things worse! By following O.O. and learning to eat "from the inside out", my body tells me what and how much it needs. Our web site FAQ addresses diabetes - www.overcomingovereating.com/faq.aspl

Bob M: I also want to say Jo, and for everyone here, if you have a health problem, like diabetes, it's important to also consult your doctor. You don't want to do something that kills you.

Also, I have been thinking about the earlier questions and comments regarding "society's standards" and the depression that may result from "being looked down upon". I know from people who visit our chatrooms and from other conference guests, even talking about other disorders, there's a common theme of "find support", people who want to better themselves and help you be a better you. There's a saying: "misery loves company". Be with people who want to better themselves, not drag you down to their point in life.

Jacki Barineau: I'd like to say just one more thing! I know it sounds like we're saying to just "pig out" all the time and not to worry about it anymore. However, in reality we find ourselves eating WAY less when using this approach! It's the fact. We have a "choice" now and no one "out there" is trying to dictate what we eat or how we live. This is VERY empowering! By the way, our website is at: www.overcomingovereating.com. The two books on "Overcoming Overeating" are there, with the ordering info. I highly recommend them!

Bob M: And by the way, while Jackie is still here, I want to add, you'll notice she didn't say she's working her way down to 120 or "model thin". She admitted she is still overweight, not as much as before, but she is more comfortable about herself as an individual than she was in earlier years. And I think that's a key point about tonight's conference also. Thanks Jackie, for being here. For those in the audience, I hope you received some positive information.

Jacki Barineau: Good night!

Bob M: Good Night.

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Bob M: IT'S EATING DISORDERS AWARENESS WEEK: I want you to know that I DO LISTEN to your comments and suggestions...and that while many times we do have experts on to talk about various disorders and the latest treatments, etc., it is also nice to talk with someone who has been through the disorder and is dealing with it...and that way we can get a different perspective. Tonight, I want to welcome Amy Medina. You probably know her as "Something Fishy". Amy is the webmistress of the site and really does a wonderful job. There is so much information on eating disorders there. If you didn't know, Amy also is dealing with her own eating disorder, Anorexia. That's why I invited her onto our site tonight, to have her share her story of what it's been like for her and those close to her...and how she has dealt with that. Good evening Amy and welcome to the Concerned Counseling website. Can you start by telling us a bit more about your eating disorder and how it started?

AmyMedina: Hi Bob... and everyone... sure. I am in recovery for Anorexia and have been suffering with it for approximately 11 years (since I was about 16). I've suffered through 3 types of Anorexia... compulsive exercising, purging-type and also the restriction/starvation type. There are a number of "anorexia causes" that I feel played a role... one of which, in the beginning stemmed from an inability to cope with stress and a need for acceptance from my peers.

Bob M: For those who don't know, could you briefly explain what the 3 types of anorexia you've dealt with are?

AmyMedina: Yes. Compulsive exercise type is driven by the compulsion to over-exercise to burn calories and energy. Some do it with aerobics or jogging, bicycle riding or excessive walking. Purging type Anorexia is trying to "get rid" of food from the body, after any consumption of food, through self-induced vomiting, laxative abuse, or enemas. Restriction/starvation type is starving oneself of some or all types of food and calories. Some also eliminate very specific things from their diet, like items with sugar and fat.

Bob M: You experienced your first symptoms of anorexia at 16. Can you remember what was going through your mind at that time? Were you concerned about developing an eating disorder?

AmyMedina: Probably in the back of my mind I was thinking about an Eating Disorder, but I don't believe it was on a conscious level. At the time I was cutting high-school a lot, and I desperately wanted acceptance from my peers and my father. My parents were also going through some marital problems at the time, which was a bit confusing.

Bob M: So, was the eating disorder something that just "snuck" up on you?

AmyMedina: I'm not sure it completely snuck up on me. My father had said to me once "you better not be Anorexic." So, I think at some point it became a way to get back at him or get his attention somehow. As it progressed, I became more and more aware that I had a problem.

Bob M: What, if anything, at that point did you do about it?

AmyMedina: Nothing! I didn't do anything about it until a year later. For me, it always seemed to wax and wain. During more stressful times I was "more Anorexic." During less stressful times, I was less concerned with what I ate and didn't. It all hinged on my happiness inside and it didn't really start to escalate until I was about 21 or 22.

Bob M: Can you tell us, what has been the worst part of it for you over these years?

AmyMedina: Physically, it was scary knowing that what I was doing could hurt me or kill me, yet feeling like I HAD to do it. Emotionally, watching the people around me who love me worry has been very hard... and then the working through recovery and finding out a lot about myself has been difficult. I also worry a lot about my own daughter, and that is VERY hard.

Bob M: So we can get a sense of your experience....before the eating disorder, what was your height and weight. And at the worst point, what had your weight gotten down to?

AmyMedina: Well, at 16 years old and 5'4 inches tall, my weight averaged between 115 and 125. At it's worst, at 5'5", I weighed about 84 pounds.

Bob M: For those just joining us, welcome to the Concerned Counseling website. We are speaking with Amy Medina, who is "Something Fishy" about her own struggle with the eating disorder Anorexia. We will be taking your (audience) comments and questions in just a minute. Can you share with us, how it came to be that you realized you needed professional help? (anorexia treatment)

AmyMedina: Part of it was through the internet Bob. I was involved with the Eating Disorders newsgroup and met some wonderful people, one who has become my closest friend. She and I have been battling recovery together. The other part of it was needing to take responsibility for myself and my family. I wanted to get this out of my life so I could be happy and so I would be around for my daughter.

Bob M: And so how many years went by from when the anorexia first set in, before you got professional treatment?

AmyMedina: Well, it set in when I was around 16. I truly came out of denial about it when I was about 24, and then really went for professional help when I was 25. So, almost 10 years.

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Bob M: Please detail for us what kind of treatment you have received over the years and briefly discuss how effective it's been for you.

AmyMedina: Let me start by saying that I am a firm believer in "what works for one doesn't necessarily work for another." Treatment and recovery are VERY personal choices. I have been in therapy. Therapy has worked well for me, especially when I have a good bond with my therapist. The therapist can be that objective outsider to offer suggestions on self-exploration. I have done a great deal of writing in a journal (not logging what I eat, but emotional things). It's helped me to come to a lot of realizations about myself and my feelings related to experiences. And doing the website and all the contact I make with other victims has really helped me. Through helping others, it helps me to help myself and face the realities of an Eating Disorder. Exploring my own spirituality, what I believe and don't believe, has also offered me a sense of comfort and self.

Bob M: Have you ever taken medications to help you or been hospitalized because of the anorexia?

AmyMedina: No Bob, but that was a personal choice I made for myself. I did have a therapist suggest Prozac and my decision was not to take it. I have always been the type to not take medications for things, even headaches.

Bob M: So, at this point, would you say that you are "recovered," in the sense that you are eating "normally" or do you still struggle with that?

AmyMedina: On all levels, I am still in recovery. I eat better than I have in over 12 years, but I still have hard days because I am still in the process of learning how to effectively cope with stress, pain and life in general. I feel confident though that I am healthier than I have been in a long time.

Bob M: I want to post a few audience comments first. Then, we will go to the audience questions for Amy.

Margie: I've been through the same three types.

Issbia: This is in reference to what Amy said about her father. My parents told me a few times that I needed to lose weight because I was "starting to get pudgy," which makes me wonder why people don't know how to talk to other people.

Marissa: I feel the same way.

Bob M: Here's the first question, Amy:

Rachy: How can people spend years in denial? I mean, I know I have some issues, but I don't think I have a full blown eating disorder. But if I did, and it did develop into something I couldn't handle, I would know. The weight loss alone should be an indication, shouldn't it?

AmyMedina: Rachy, well the weight loss isn't always so drastic in the beginning and the analogy I often make about denial is this...Your Eating Disorder becomes a sort of friend to you and that friend gets closer and closer. By the time you realize it's a problem, that "friend" already has you fooled and you have a harder and harder time believing it's really your enemy. So giving up the Eating Disorder is like trying to say goodbye to your best friend and killing your enemy all at once.

Dewdrop: Did you feel that you were in control of your eating disorder? I know I feel totally in control, but now I am beginning to consider that to be an illusion.

AmyMedina: It is an illusion and that is part of it. In the beginning, you like the control it gives you, but at some point that control begins to shift and the disorder has a stronger grasp on you than you realize. I believed I was in control long after I had lost it, Dewdrop.

Bob M: Onto more questions:

Chimera: But because of this disorder, I barely have any friends left. I haven't told anyone, but everyone finds me not very much fun to be around. My friends have given up with me lately and I don't know how to do this without having any support from friends. I read a lot of info saying that social support is very important in dealing with something like this. How am I supposed to deal with this if the only friend I have is a disorder that wants to kill me?

AmyMedina: That's part of the hard part. You have to say to yourself every day that you deserve to get better, that you deserve to be happy. Then you have to take the step to reach out to others and just ask for help and support. If you don't feel anyone in your immediate life can give that to you, than you have to try to find it through anorexia support groups, therapy, someone new in your life, a teacher, an aunt or uncle, or even start with chatrooms on the internet. You need to remind yourself every day too, that you are not alone.

Bob M: And Amy, that's one thing I have found that is common among people with eating disorders...the loneliness, the isolation.

AmyMedina: That's very true Bob. It was the initial goal of my website, to remind victims they are NOT alone.

Bob M: What has been your family's (mom, dad, siblings) reaction to your disorder?

AmyMedina: To be completely honest, I have never actually talked to my father about it, though I know I will have to someday. My mother has been wonderful. She is not afraid to ask me questions and has been honest with me about the whole thing (as a matter of fact, she's here tonight! HI MOM). My husband has been great too, in trying to learn about eating disorders and how he can help me better than just by asking me to eat something. I feel very lucky to have the people in my life that I do.

Moira: I think my ED has to do with the fact that I feel responsible for all the world's woes. Can you relate to this and how can I stop it?

AmyMedina: Yes, I can relate to that a great deal. Somehow, I've always felt that the more I help others, it makes me a better person. Truth is, you are the BEST person you can be when you love yourself. It's so common to find Eating Disorder victims to be the type that want to help everyone else but themselves. There is no sense of compassion towards your own problems. You need to start to validate them to yourself and say "I deserve help too" and "I deserve happiness" and most of all, realize that you are not to blame, nor are you responsible, for the world's problems. I know it's hard Moira.

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Miktwo: How did your husband handle your ED?

Bob M: Specifically, dealing with your anorexia, does it put a strain on your marriage and how have you and your husband handled that?

AmyMedina: It is hardest on my husband in the day-to-day setting because he is the one to deal most with my mood swings and when I'm having a hard time. He is a musician, so he deals with some of it through music. We also have a wonderful relationship where we can communicate and I trust him a great deal. His biggest help to me has been his ability to learn about the Eating disorder and to listen to my needs. It IS a strain on the marriage and his biggest fear is that I will die in my sleep. I often caught him checking to see if I'm breathing at night.

Bob M: Here are a few more audience comments:

Marissa: I had a lot of abuse including sexual abuse. My eating disorder started at age 10.

Marge: You talk about three types. It seems to me, it's all the same thing. It's a merry-go round. You just keep switching horses. I was dancin' 4 hours a night, didn't eat for four months, and I still was arguing with my Doctor. I said I was "Just on a diet". The reason I was at my Doctor's was someone told him to insist I come in to see him.

Dewdrop: I never knew there were three types, but now I realize I need help since I do fit in all three.

Issbia: Rachy, the weight loss isn't viewed as a problem, it's viewed as a solution to a problem.

DonW: Compulsive eating is slowly killing me. I hate to say that the only time I felt I ate normal was when I was on Redux.

Bob M: Here's the next question Amy:

cw: Bob, can you ask her how she handles the feeling of being fat as she achieves a healthy weight?

Marissa: How do you get rid of the feeling of "feeling fat" and not wanting to gain weight?

AmyMedina: It's tough! I have to remind myself out loud every single day that my self-esteem does not hinge on what I weigh, that regardless of my weight I am still a good person. I also do not own a scale. I do not judge how my day is going to be on what that number says in the morning and when I eat, I tell myself, remind myself, that it isn't going to make me balloon up 10 pounds over night, or even 1 pound... that I NEED this food to keep me healthy and to keep my heart beating. I still have a tough time with it when I'm having a very hard day, but I just keep reminding myself ALL the time, that it IS okay, CW and Marissa.

Solidarity: I have had anorexia since I was a newborn, neglected of food and all else. What are the side effects, risks, and what may I have already damaged in these 26 years? (complications of anorexia) I don't over exercise. I just forget to eat or don't eat properly.

Bob M: As Amy is answering that question, I want everyone to know that she is not a Dr., but she has a great deal of knowledge on the subject.

AmyMedina: The side effects and dangers are quite numerous. Most common is dehydration, malnutrition and electrolyte imbalances, all of which can cause you to have a heart attack and die almost instantly. Also, some other dangers are kidney damage and failure, liver problems, osteoporosis, TMJ syndrome, chronic fatigue, vitamin deficiencies, stroke, seizures, edema, arthritis (specifically osteoarthritis).

Somer: Did Amy ever go through the Binge/Purge cycle?

AmyMedina: No Somer, I have never suffered with bulimia (binge/purge cycles), but one of my closest friends does.

Mattymo: Amy, do you believe that in the end, the weight issue is so often clouded, and it is more to do with having a release, a way to keep stability in one's life?

AmyMedina: Yes, I believe the weight issue IS often clouded. A lot of people suffering with Anorexia seek control over their lives. A lot of bulimics look for a way to release emotion and forget pain. (I'm generalizing of course)

Jo: It's weird Amy. I am a compulsive overeater and very obese. I hate the word, but I am. I wanted to be anorexic to lose the weight until I saw all the pain -- same pain. It's hard to deal with sometimes, when I realize the pain an anorexic goes through all because they "think" they look like me. I can see that a lot of the problems and "solutions" are the same, but why is it -- this 'fat' thinking?

AmyMedina: It's different for everyone Jo, their perception of themselves. But ultimately, it all hinges on self-esteem and how it translates. It's like looking into one of the circus mirrors. On days I feel bad about myself, if I look in the mirror, it somehow translates to me seeing what I don't like. Because of society, part of that is seeing what is considered "unacceptable" in myself.

btilbury: Do you have other compulsive behaviors? I tend to move frantically from one compulsion to another, just to keep ahead of the emotional turmoil.

AmyMedina: I had a borderline alcohol problem some years ago. I also have workaholic tendencies which I have to fight every day (and don't always win!)... I am the major perfectionist about my work.

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Bob M: Here are some audience comments:

Chimera: I don't feel like I can do anything. I feel like the only person on the planet most of the time. I know in my head I am not alone, but I feel lonelier than I ever have, Amy.

Rachy: I know I have some "food issues". I just feel like this is the first time I've had control. I mean, I lost 40 lbs since January 7 and I'm happy about that. I look exactly the same so, I can't stop just yet. I know it isn't healthy, but I'm just not at my goal yet. When I was heavier, my husband and family made fun of me. Now that I've dropped 40 lbs, they act as though they haven't noticed. Why is that? I end up feeling like, "Huh, I'll show them. I'll just lose more."

Bob M: Here's the next question, Amy:

Thora: I fast for days and then eat a little and purge it. I have been doing this for quite some months, and have lost weight, but don't feel sick or bad in any way. Am I still doing damage then?

AmyMedina: Yes, absolutely! Fasting for days and then purging when you do eat, puts you at all the risks of Anorexia AND Bulimia. Purging REALLY messes with your body's hydration and nutrition levels very quickly and screws up your electrolytes. You are at an increased risk of having a heart attack in your sleep and dying. Purging also screws up your body's ability to absorb nutrients, so when you do it, you are not getting the most out of what is in the food Thora.

Bob M: I also want to welcome Cheryl Wilde to the Concerned Counseling website tonight. She also has a wonderful eating disorders site on the net. It's dedicated to her sister, Stacy, who has really struggled with anorexia. We are going to have them both on our site next month to talk about what they've gone through together. Here's a comment from Cheryl:

Cheryl: I talk with Amy about the dangers of starving, dehydration and laxative abuse. My son, a high school wrestler, does this to make weight.

Bob M: Are you scared Amy that maybe you have "passed on" your anorexia to your daughter and that someday she will have to deal with it herself?

AmyMedina: I worry about that a lot. I worry about the predisposition to depression she may have, and I worry that she'll have this desire to try it because mom was that way one time and look, she's still alive. I pray and hope it never happens and hope that my openness and education prevents it. It's a very scary thought to me Bob

Bob M: Here are some more audience comments:

Stacy: Amy, I wish that I could not judge my day without the scales. I am so afraid of gaining weight. I have gained 5 pounds this year, and I feel like...you know.

sick_and_tired: I have been in 8 different treatment hospitals for my eating disorder. Does it ever get easier?

Bob M: Amy just got booted. She'll be right back. As we wait for her for a moment, I want everyone to know we appreciate your coming to our website. It is very rewarding for us because we get so many positive comments through the email every day. And we are glad that you are finding the information and support you are looking for. I see Amy is back. Here's another audience question:

TWK1: How do you make yourself eat when you have no appetite?

AmyMedina: Sometimes, if I don't want to eat, I have to force myself to make sure I do, reminding myself the whole time that it's okay! It's not easy and there are times when I don't. But for the most part, now, I eat when I'm hungry and that usually consists of two good meals a day and a good snack. I also drink a can of Ensure each morning.

Cubbycat: Are your hunger/fullness cues normal now, or has the anorexia altered that? I found that binge eating and purging messed me up and I have trouble telling whether I'm hungry or if I'm full.

AmyMedina: My hunger cues are still a little messed up. But for the most part, I can tell when I'm hungry. If you have a hard time with that the best thing to do is see a good nutritionist who has a LOT of experience with Eating Disorders. Sometimes, for some victims, 6 small meals a day works better than the typical "3 square meals a day" and it does take a while to get used to the feeling of hunger and fullness again. You have to allow yourself the adjustment time.

LCM: Amy or Amy's mum: My mum attributes every down day, every little tear or pout to a 'relapse' or further decline in my (mental) health. She is clearly overreacting. As a mother, is there anything I can say to make her understand that a 'bad day' is not necessarily a sign of 'doom'?

AmyMedina: LCM, I can't speak exactly for my mom, but the one thing that has helped my own mom and what may help yours is to get some therapy herself. This will help her deal with HER issues surrounding your Eating Disorder and recovery and will also be an objective opinion that she may be more responsive to. Parents need support through this too.

Peanuts: Sometimes I lose so much weight that everyone thinks I'm gonna die. Then it seems like I go on a binge spree and can't stop. I'm on a binge spree now because I'm so depressed with the weight I've gained I can't handle leaving the house. What's the best way out of getting out of a binge spree or is there one? I'm feeling totally hopeless.

AmyMedina: One of the best ways to get out of a binge spree is to not starve yourself. When you restrict your calories and fat intake your body goes into a "starvation mode" so that when you do it, your mind wants you to keep eating, as if you are stockpiling for the next fast. Also, if you haven't already, reach out for some help. Take some small steps to find support. Work on finding your own underlying causes for the ED.

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Bob M: Here's a comment from Amy's mom. I asked her how she is dealing with Amy's eating disorder:

FISHYMOM: It has been hard not to be so scared all the time for Amy. I have learned to trust her though. She has come so far. And we talk. That helps.

Bob M: Another common thing I find Amy, is that so many young people in their teens are afraid to share what is going on, their eating disorder, with their parents. Can you address that?

AmyMedina: It's very hard for ANY victim to share their Eating Disorder with anyone. There is the aspect that they do not want to give up the security it provides them and there is still a lot of shame attached to eating disorders within society (unfortunately). I think teens have a particularly hard time because a lot of them are just getting "into" the ED. A lot of them enjoy the acceptance from their peers when they hear "you've lost weight and look great" and I think a great number of them are still in denial as to the severity of the problem, or that it is even a problem at all.

cubbycat: I used to be full-blown bulimic (purging with laxatives). Then I started to pass out, so I quit the laxatives 10 years ago. I fooled myself into thinking that I no longer had a problem, but food is still how I handle my emotions. When you were first recovering from the anorexia, was there any tendency to cross over into bulimia or binge eating disorder?

AmyMedina: My transitions stayed within the bounds of Anorexia, switching from the exercising to the restricting to the purging and back and forth. It is VERY common for victims to waver between all three Eating Disorders though, anorexia, bulimia and compulsive overeating.

Bob M: Do you ever feel like just "giving up"...that it's too much of a struggle? How to you handle it when those times come around?

AmyMedina: That's an easy one for me, Bob. I still have times where I think it would be easier to just go back to the Anorexia, but then I look at my daughter and for her I can't do that. I also hate the thought of just being that depressed all the time again.

Bob M: Here's a few more audience comments:

UgliestFattest: I was exercising 10 hours a day and eating about 250 calories a day and taking 12 laxatives a day. I still denied that I had an eating disorder. There are times that I still feel that I don't have an eating disorder. Have you ever gone through that (where you know you have an eating disorder, then you are denying that you have one the next moment)?

Rachy: That stuff doesn't happen for a while. I don't even look like I have a problem. I can stop before any of that happens to me.

Marge: I lost 86 pounds and my husband didn't seem to notice.

Moira: Thank you for being so honest with us, Amy.

AmyMedina: I would like to address Rachy's comment specifically if I can Bob! Rachy, there are victims that die everyday that are not typically "underweight" or that don't look like they have a problem. The dangers all happen internally and very little hinges on what you weigh! UF: denial is a powerful thing, especially when you cling to your Eating Disorder for support and for the feelings of control it gives you. I have often been through times of denial, knowing I have an eating disorder, but thinking "ah, so what, nothing will happen to me." But believe me, those "nothings" DO happen.

SocWork: So Amy what would you say are the resources and strengths that you rely upon in dealing with the disorder? It appears that one of them is your concern for your daughter.

AmyMedina: Yes, one of them is that. The biggest strength I rely on is myself, and continuing to find the desire within me to get rid of this for good. I can't help but think "if I'm so good at being a perfectionist about everything, than I can be good at recovery too!" I WANT that because I want to be happy and healthy. Resources for me have been therapy and journal writing. I truly need my writing to help me cope with my emotions. I've come to a lot of realizations and conclusions about myself through that writing.

AmyMedina: I believe BobM got disconnected for a moment. While we wait for him to come back, let me take this opportunity to thank EVERYONE for sharing your comments and questions with me. I know it's not always easy to talk about this subject. You are all beautiful people!

Bob M: Sorry about that. El Nino just struck our building in San Antonio, Texas with a bolt of lightening. I think we are going to wrap it up for tonight. I want to thank Amy for coming tonight and sharing her personal story with us. It takes a very courageous person to do that and I'm sure some of the personal questions were tough for her to answer. I hope though for those of you here, it gave you some insight to what an eating disorder is all about and also, there is hope. But it takes some strength and the ability to reach out for help so that you can work through it. Amy, I would appreciate it if you would give your website address.

AmyMedina: Thanks Bob. I just wanted to tell everyone if you struggle with an Eating Disorder (and I'm sure a lot of you are struggling right now) PLEASE by all means, come and visit the website. You are not alone. There is support for everyone there, from victims themselves to their loved-ones. The url is http://www.something-fishy.org/

Bob M: Again, thank you Amy for being here. Tomorrow night, as we continue our series for Eating Disorders Awareness Week, our topic is "Overcoming Overeating". Hope to see everyone back here then and pass the word around to your friends or net buddies to drop in. We have received many favorable comments from people about how coming to the conferences and getting information has been the start of their "recovery".

AmyMedina: Thank you for the opportunity Bob. I truly appreciate the chance to communicate with everyone.

Bob M: Good Night.

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Bob M: Our topic tonight is Diet Drugs and Weight Control. We get emails daily about the diet drug controversy and other weight control issues. That's why we've brought Dr. Ben Krentzman in to be our guest. Dr. Krentzman is an M.D. in California. He is an expert on the issue of weight control, obesity and diet drugs (eating disorder information). I believe his entire practice now consists of working with patients concerned about their weight. Dr. Krentzman also has an extensive internet site and we'll be giving you the URL at the end of the conference. Good Evening Dr. Krentzman. Can we start off by you telling us a bit about your expertise?

Dr Krentzman: Thanks Bob, For the last 23 years I have been interested in obesity. I switched from being a Board Certified Family Physician to only taking care of obesity patients in 1993. For the past 2 1/2 years I have maintained the largest website on obesity and have continued to research this subject. My Curriculum Vitae is online on my site.

Bob M: I'd like to start off by having you define "overweight" vs. "obese".

Dr Krentzman: Overweight is defined as being over 20% heavier than the Insurance companies Ideal Body Weight chart for your height and weight. Obesity is having too much fat on your body. You can be overweight and not obese if you are a weight lifter. The Body Mass Index (BMI) is a single scale used by obesity researchers as a measure of fat. It is a combination of height and weight to give one number. A BMI of 22 is considered about ideal. On the BMI scale the government says that 25 or above is overweight and 27+ is obese. The BMI does not measure fitness.

Bob M: What is the cause(s) then for being overweight vs. obese.

Dr Krentzman: Mostly people are overweight because they were born with the genetics which lead to being overweight. The genes are the program within our bodies that tell our brains how to operate. How we process food seems to be of little importance to obesity. There is an organ in the brain which regulates how much fat our body maintains. That organ is the hypothalamus and through a complex of neurotransmitters in the brain and the sympathetic nervous system, it closely regulates what we want to eat.

Bob M: So, if being overweight or obese is a function of genetics, what then is the point of dieting? (dangers of dieting)

Dr Krentzman: Since the success rate of long term weight maintenance is 2%, I do not see much point.

Bob M: Alright. Now I guess is as good a time as any to bring up the diet drugs. And I want to mention, before we get into it, that everyone here I imagine has heard the FDA warnings about taking fen-Phen and other diet drugs. It is very important that you check with your doctor before taking any weight control drugs.

Dr Krentzman: There is a tremendous amount of misunderstanding about the announcements in the press. The media has missed the point. The Mayo Clinic Press Conference on 7/8/97 was an announcement of a suspected condition (heart valve disease) which MIGHT be connected with obese women. At the press conference, a transcript of which is on my website, the doctor reading the message said that NO patient should stop their medicines without talking to their doctor. There is NO PROOF of any long term problems with the diet drugs as there has been only one article of a study longer than one year. All others are shorter.

Bob M: Are you saying, contrary to the FDA warning, that taking drugs like Fen-phen and Redux is safe?

Dr Krentzman: No, I am saying that the "Warning" is a routine way that the FDA asks all the doctors in the USA to be on the lookout for similar problems and to phone in with case reports when we find one. So far about 70 cases have been found out of the 8,000,000 users of diet drugs. Compare this with the 300,000 people who die each year from obesity related illnesses.

Bob M: Everybody has been so patient in the audience. I want to let a few audience questions on, then we'll continue with my questions. We are talking with Dr. Ben Krentzman. Dr. Krentzman is an expert in obesity and weight control. He has an extensive website on the subject and I'll be giving you his URL at the end of the conference.

Lady: I have never been to a conference, but I have a question... Why is it soooo much harder if you only have 20 pounds to lose than if you have 100 ?

Dr Krentzman: It is not harder. If you have, for instance, two people who are 5 foot 7 inches tall and one is 150 pounds and the other is 250 pounds then it takes more calories to keep the 250 pound person at that weight. Therefore they can burn more calories in a day than the more slender person can.

River: Whether or not there is proof, why would anyone want to create health problems in addition to their weight problem.

Dr Krentzman: The FDA asked our help in finding cases so they could get some idea if the diet drugs are somehow involved with heart valve illness. This has not yet been proven, only partly suggested. These may be the only 70 cases in all of time. Should this cause tens of thousands of obese people to die by avoiding the diet drugs WHICH WORK?

River: I understand your point. BUT my overweight is my only health problem (30 pounds) and although I've considered taking the drugs, I've decided against it because of the FDA warning. I guess the choice is the health problem I understand vs. the health problem I don't. Ultimately, it's a consumer choice.

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Bob M: Can you please explain when it is appropriate to consider taking diet drugs like Fen-Phen and Redux?

Dr Krentzman: Anyone who has a BMI of 30 or more will benefit. Those with less weight (you can see a BMI chart on my website) can benefit if you are a BMI of 27 or more and have heart disease, diabetes or hypertension. Dr. Koop, former Surgeon General of the United States believes that Diabetics could benefit down to a BMI of 20 I will not help anyone lose weight below 20 because that is where lifespan begins to shorten.

Bob M: What is the difference between Fen Phen and Redux and what is each indicated for?

Dr Krentzman: Phen/Fen is made up of two separate drugs, Phentermine and Fenfluramine. Redux is made of one drug which is the active weight controlling half of Fenfluramine (Pondimin).

Bob M: But do both do the same thing? And what are the side effects of each?

Bob M: While Dr. Krentzman is answering that question, here's a couple of audience comments.

Rhonda S: I've been on redux a little over a week I have lost 4 lbs and I have trifold the energy I had before taking the drug. The only side effect I experienced was a horrible headache that lasted 4 days.

Lori H: I was on fen-phen for a few months and gained 15 pounds.

Dr Krentzman: Phen/Fen is made up of two separate drugs, Phentermine and Fenfluramine. Redux is made of one drug which is the active weight controlling half of Fenfluramine (Pondimin). In other words, fenfluramine and redux are the same. The side effects are identical. No one has ever given me any proof that my belief, loudly stated on my website, is wrong. The most common side effect is dry mouth (90%). Drowsiness occurs in about 40%. Less than 1% have diarrhea or constipation and even less have mental confusion or short term memory problems. All these side effects go away when the level of medicines is reduced or stopped.

Dr Krentzman: For the person who wondered why they could gain 15 pounds of Phen-Fen, The medication combination works on 60% of humans, and not on 40%. Since all other ways fall in the 2% success rate, the diet drugs are the best odds you can get. About 15 more medicines are in the research pipeline. See my site for details.

Bob M: I have heard, and you are the expert on this...Is it true that once you start taking these diet drugs that you shouldn't stop for the rest of your life?

Dr Krentzman: Yes Bob. IF you stop taking the medicines, there is a 98% chance that you will regain all the weight you lost over the next 5 years (or sooner). There was an article by a panel of obesity experts, called together by the National Institutes of Health to review the literature. They concluded that if you stop the medicines EVER you will regain ALL the weight you lost. (JAMA 18 Dec 1996). They said that using the medicines for less than 12 months had no value and that there was only one small study for over 12 months so they could not recommend using the diet drugs for longer. My study is 26 months along with 800 patients and no unusual problems. Another doctor here in Los Angeles says he has treated 20,000 patients in his 18 clinics without any strange problems. UCLA says they have treated 1000 without problems.

PEDSI: What good do these diet drugs do if you have to stay on them to prevent the weight coming back?

Dr Krentzman: What good does insulin do for a diabetic if they have to stay on it for life to prevent dying from diabetes? What good are eyedrops which prevent glaucoma from causing blindness? This is like asking an asthmatic to stop wheezing without taking their medicines. In all cases, including obesity, nothing is cured, only controlled. The diet drugs, if used a lot, could reduce that 300,000 deaths per year caused by obesity.

Mary33: Hi. I'm on a drug called Fastin (phentermine), what is the danger of it? I have recently lost 14 pounds in three weeks.

Dr Krentzman: No deaths have been reported associated with phentermine.

Bob M: If a person doesn't want to take drugs, what other ways, either dieting or surgical are there to lose weight?

Dr Krentzman: There are no other ways that work over the long term. Any time you reduce the total calories you take in, you will lose weight. The pills do this for 60% of the people who try them. Today I saw a 5 foot one inch lady who has lost from 150 lbs to 117. She went down to a size 3 and is now in maintenance. For those who are severely overweight, 40 BMI or greater, surgery has a 73% success rate. It is really worthwhile talking to someone who has done 100 or more of these operations. They work.

Liz: I am interested in drugs other than phen/fen and Redux. What other drugs are there out there and how effective are they when compared to Fen-Phen and Redux?

Dr Krentzman: There are a few drugs in the same classification as phentermine which are approved for use and do work. Phendimetrizine is one I use as an additional drug. It, and the others, are no more effective than phentermine, just different enough so that I can get around strange reactions and allergies. Fenfluramin and Redux and one other rarely used medication are in another classification with fewer alternatives. These drugs release the neurotransmitter serotonin. There are about 6 other classes of drugs which increase the serotonin in the brain. They are not more effective and are considered less effective.

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Bob M: Many people, as you mentioned before, who diet, complain that keeping the pounds off is very tough. What is the correlation between taking the drugs and the need to exercise?

Dr Krentzman: There is very little use in moderate exercise. Since I am the only person who is trying the medicines without diet or exercise, and it works, this is an unstudied field. Moderate exercise can lower weight 5 or 10 pounds with diet. Then you must do this all the rest of your life.

Bob M: We are taking audience questions for Dr. Krentzman. If you're just joining us, Dr. Krentzman is an M.D. He's a nationally known weight control specialist and has written articles for professional journals as well as being interviewed as an expert on the subject by Time Magazine and I believe, he also recently appeared on the CBS newsmagazine, 48 hours, on their show on obesity.

Tina: Do your patients change their diet and exercise habits in addition to taking the drugs? Do they continue these changes after their weight loss?

Dr Krentzman: My patients sometimes change these habits. I ask all my patients to NOT DIET for the first 8 weeks. In this way I can tell if the medicines are working. If they diet, they WILL lose weight. But I won't be able to tell if the medicine helped. I tell my patients that exercise is good and very healthy and will help them to live longer.

Bob M: What about diet products like Herbal-life and herbs, etc. How effective are they?

Dr Krentzman: No better than dieting without them.

Bob M: To change the subject slightly for a moment. There have been articles recently tying obesity to depression. Can you address that?

Dr Krentzman: I have not seen any studies which show that the obese get more depressed than the thin. One big study by Stunkard gave psychological tests to 300 people before surgery and 600 random people (thin and fat). A year later they retested them and found both groups had the same amount of problems. The surgical group had lost an average of 60 pounds. Divorce, jobs, hospital admissions, illness, mental testing, all were the same. Obese people are not crazy. They are just obese.

Bob M: No. I am not saying they are crazy...and I don't consider being depressed as crazy, but I have heard overweight people say they are depressed and seen stories relating the two.

Bob M: Here's an audience comment on that subject...while we're waiting for Dr. Krentzman's reply.

Diana: Some depressives overeat while depressed, so it wouldn't be surprising.

River: Overweight people seem more unhappy, if only because we have such an image-conscious culture. It is depressing to be fat.

Dr Krentzman: I agree with River. Our culture has a lot of bigotry built in about being fat. I am saying that obese people get depressed with the same frequency as the nondepressed.

Geonurse: The Florida Board of Medicine just banned fen-phen for 90 days. What is your view on that?

Dr Krentzman: Yes, Geonurse, I believe that they have been pressured to do this and to allow those people succeeding in keeping weight off to go ahead and die. For the very overweight that is the alternative. Those 300,000 deaths per year loom large against the lack of the expected Primary Pulmonary Hypertension death increases. Today, I called a friend who is a pulmonary specialize in a 6 man group. He said he had never seen a case of PPH in his 25 years and neither had any of his partners. It is so rare, he never expects to see one. None of his literature tell of an increase in the number above normal. Where are all those dead bodies the media lead us to expect?

Bob M: Is there a different reason for obesity in men vs. women and are diet results different when it comes to the two groups?

Dr Krentzman: Not in my program. We have 60% success in both men and women. I cannot yet answer about reasons because there has been too little research in this area. Until recently obesity was a stigmatized condition and no real money or research was done. This is why my program of not dieting is a landmark. Strangely enough, no one else has done it.

Bob M: I just noticed that Dr. Krentzman has been with us for nearly 2 hours. So we are going to call it a night. I want to thank you Dr. for joining us tonight. There are many more questions the audience has, so I'm hoping that sometime in the next 2 mos. we can have you return. For more info you can visit Dr. Krentzman's very complete obesity/weight control website.

Bob M: Good Night.

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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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