Doctor Sheds Light on Treating Eating Disorders
March 5, 2007 — -- While eating disorders affect millions of Americans, until recently, people in the medical community didn't fully understand them.
Dr. Ira Sacker changed that 20 years ago when he wrote "Dying to Be Thin," the book that revolutionized how people regarded eating disorders.
For more than 35 years, Sacker has been working with anorexics, binge eaters and bulimics, and shedding light on conditions that were long in the shadows.
Now, Sacker is out with a new book, "Regaining Your Self," in which he pioneers advice on how to fight eating disorders.
His new approach deals with more than just getting people to eat. Instead, he focuses on dealing with the patient's lack of personal identity.
Just as his first book did, "Regaining Your Self" is poised to revolutionize how the world thinks of eating disorders. You can find more at www.sackermd.com.
Read an Excerpt from "Regaining Your Self" below:
INTRODUCTION
Discovering the Self
My first patient with anorexia was sixteen years old and on the brink of death from malnutrition. I had no idea what to do.
Until a few days before, I had been a young resident in pediatrics at New York University and Bellevue Hospital Center. On that day in 1970, I was a brand-new fellow in adolescent medicine at Los Angeles Children's Hospital. I had arrived at the hospital first thing that morning, bleary-eyed and jet-lagged, expecting to spend the day meeting the big shots who had started this pioneering program. Instead, when I introduced myself to the head nurse, she said, "Your patient is waiting for you on the adolescent floor."
"Excuse me?" I said. "Isn't there some sort of orientation I need to have first?"
"We'll get to the orientation later," she replied. "They want you up there now."
I was a little surprised and not feeling particularly confident, but I was eager to make a good impression and begin work in my new position. I was also so new to the hospital that I had to ask how to get to the adolescent floor. From inside the elevator as it approached the ninth floor, I could hear enraged screaming. As I arrived in the reception area, I saw where all the noise was coming from: A teenaged girl was in a hair-pulling tug-of-war with her mother, all the while cursing her at the top of her lungs. The mother seized the girl's handbag and turned it upside down. Dozens of tiny white pills spilled out all over the floor.
I knew right away this was my patient. I was still a young doctor back then, but I had been in medicine long enough to realize that the hospital staff had dealt with this girl before. They knew I was coming and were taking advantage of the new guy by passing a difficult patient off to me.
The nurse behind the reception desk took one look at me and pointed at the battle going on before us. "You must be Dr. Sacker," she said. "That's Julia. You can use exam room A."
I somehow managed to get Julia and her mother into the exam room without getting punched in the process. When I was able to take a closer look at Julia, I was shocked. This blue-eyed, blond girl was about five foot four and terribly underweight. She looked as if every bone in her body could break at any moment. She was so thin I couldn't understand how she could even stand up, much less put up such a fight. In fact, I couldn't really understand why she wasn't dead.
Putting on my best professional manner, I introduced myself: "Hi, I'm Dr. Sacker, the new fellow in adolescent medicine."
Her response was short and to the point: "I don't want to talk to you." Then she resumed screaming at her mother.
Still using my best professional manner to cover the mounting panic I was feeling, I tried to get her to calm down. I looked over to her mother and realized immediately that there wasn't going to be any help there. Julia's mother was in shock and clearly needed someone else to handle this. All I could get out of her was that her daughter had been diagnosed with anorexia nervosa -- a disease I had vaguely heard of but never seen, much less treated.
I tried again and still couldn't get through to Julia. I couldn't even begin to take a history. Finally, I sent her mother out of the room, and Julia calmed down enough for me to get some much-needed information. She told me those tiny white pills were to suppress her hunger. I told her she needed to be hospitalized, now.
She looked at me, laughed, and refused -- totally, absolutely, adamantly.
I was at a loss. If this girl didn't get medical attention at once, she was going to die. I called my supervising physician (whom I had yet to meet face-to-face). Trying to sound competent and unflustered, I told him my patient was out of control, needed immediate treatment, and was refusing voluntary admission. What was I supposed to do now?
He told me that if she obviously needed treatment but was refusing admission, she had to be sent to the county hospital's general psychiatric unit. The procedure, he said, was to call a county ambulance. The attendants would come and put her in restraints; then they would drive off with her, and with any luck I'd never see her again.
Great, I thought. It's not even nine in the morning of my first day and I'm having my first patient put into restraints and sent off in an ambulance. I followed procedure. Julia was taken away. Her mother left. OK, not my problem anymore -- next patient, please.I spent the rest of the day seeing adolescents in the outpatient clinic, and by the end of the day I felt like a real doctor again. I was also completely wiped out from the combination of stress and jet lag. I went home to my new apartment and collapsed into bed.
At three in the morning, the phone rang. It was a state police officer. He told me that he had a missing person named Julia in custody. She had managed to escape from the county psych unit and make her way home to her mother's house. Her mother, however, had refused to let her in, and Julia had then proceeded to break every window in the house. That was amazing enough, but what the officer said next just astonished me: "She says you're her doctor. What do you want to do?"
Good question, I thought. "Put her on the phone."
"I'll come to the hospital," Julia said. I didn't have to say anything. She had clearly figured out for herself that between the county psychiatric unit and me, I was the better choice.
The next morning, Julia was waiting for me. She was calm, controlled, and ready to be admitted. At this point, understandably, it was her mother who was the wreck. We once again went into an exam room, and now Julia was willing to give me her medical history. She had been restricting her food intake and using appetite suppressants for more than eighteen months. She had lost forty pounds.
I told her that while I could treat her medically and save her from dying of self-starvation, she also needed psychiatric care. I very frankly told her that I didn't know anything about anorexia. As it turned out, the psychiatrist who was called in to evaluate her didn't know anything about anorexia either. In 1970, very few did.
Julia's psychiatrist gave her large doses of heavy-duty tranquilizers while I worked out a nutrition plan that would gradually help her regain weight without causing additional medical problems. At first we had to give her a liquid formula using a nasogastric tube -- an unpleasant procedure for everyone.
During the first week Julia was on the adolescent floor, I was very worried about her. I was afraid she would die of severe malnutrition despite our efforts. It was clear from the start that her sole goal and interest in life was to lose as much weight as she possibly could. Other than that, all I could tell about her was that she was an angry young woman.She refused to talk to the psychiatrist, saying instead that she wanted to talk to me. But I protested, saying, "I don't know anything about anorexia. I don't think I can help you." And yet, at the same time, I felt drawn to Julia -- something about her behavior reminded me of myself. My own adolescence hadn't been easy, and deep down I thought I understood, at least a little, how she felt. Like me at that age, she had not a clue as to her own identity.
Finally I did something I knew I wasn't supposed to do, something that went against all my years of medical training. I was taught to ask the questions and wait for the responses from the patient, and to never, ever reveal anything about myself. Julia wasn't buying it. She simply wouldn't talk to me that way -- she would sit there and refuse to say a word. After a week of this I was so frustrated that I just began chatting to her, telling her that I was originally from California, that I was in LA to learn about adolescent medicine, and that I knew next to nothing about eating disorders. Before I knew it, we had formed some sort of bond and she started opening up to me.
After two months on the adolescent floor, Julia had finally gained enough weight to be discharged. Her parents thought that because she had gained weight, she was well. So did I.
Julia continued to see me on an outpatient basis three times a week for medical exams and weight checks. She came faithfully, but immediately started to lose weight. I warned her that if she lost three more pounds she would have to go back into the hospital. That got through to her, I thought, and her weight immediately stabilized. There was just one problem: As the next three weeks went by, the scale stayed the same, yet I could see that she was getting thinner and thinner.
I was slow on the uptake, but I finally caught on to the ways she was fooling the scale. When I was able to get her real weight, she had managed to lose six pounds. That meant being readmitted to the adolescent floor for another round of inpatient treatment. This time I was less worried about losing her, and she was more open with me. I began to like her as a person: a lonely person who had been emotionally abused by an angry mother and had almost no relationship at all with her father. I discovered that hiding beneath the anorexia was a very bright young woman and an outstanding student. Despite her excellent grades, she never really felt she was good enough -- the only way she could cope with the pressures of life and feel under control was to stop eating.
At the time I didn't really know what I did to help Julia, but she regained the weight quickly and was discharged in three weeks. As before, I continued to see her three times a week in the outpatient clinic. She still met with the nutritionist and was weighed, but when we talked, we no longer discussed her weight and food. Instead, we chatted about her -- who she was, what her interests were. In these relaxed sessions, we enjoyed each other's company. Her smarts came out, her fears were no longer there, she was finally able to talk about the underlying issue of her feelings of inadequacy. We talked about everything but her weight. She told me she wanted to be an actress but her mother didn't want her to. I told her that I had wanted to be an actor but my father wouldn't allow it. Now we really had something in common.
Julia wanted to return to school so she could graduate and go on to college. Her high school, however, had failed her out for missing so many days. Doctors aren't usually supposed to get involved with this sort of thing, but I called the school and managed to get them to readmit her and let her transition in by attending just a few hours each day. By the time my fellowship was over and I had to return to New York, Julia had made up her schoolwork and had been accepted to college -- with a scholarship.
During my six months in Los Angeles, I ended up treating several other patients with eating disorders as well. The county psychiatric hospital heard about Julia and started sending me other teenaged patients with eating disorders. At first I thought that was because I had been so successful with Julia, but I quickly realized it was because they just wanted these difficult, dangerously ill patients out of their hospital.
I saw these teens as purely medical cases. Mostly I worried about making sure they didn't die -- I didn't pay a lot of attention to their emotional problems. It didn't strike me until near the end of my fellowship that there were a lot of similarities between who my patients were and who I was, that I had all the dynamics of a patient with an eating disorder. I was an overachiever, I was perfectionistic, I had my own level of obsessive-compulsive traits. When I was studying for exams, for instance, I didn't know when to stop. No matter how many good grades I got, the euphoria lasted for only a few seconds. Then my mind would take me to the next level of obsessive studying. My patients were the same way -- their expectations of themselves were completely overwhelming. Looking at these patients was like looking in a mirror.
If you had told me, back in those early days, that I would be spending all my time treating patients with eating disorders, I would have said, no way, nohow. I couldn't even find any information about anorexia so I could learn more -- it just didn't exist then. My treatment method for my patients was improvised out of anxiety, not knowledge. Fortunately, none of them died and none of them relapsed. I thought I had found an effective approach, but what I really had were young patients, early diagnosis, and not much cultural pressure to be thin. There was nothing positive in society to reinforce the eating disorder behavior. But mostly, I got lucky. I was able to be a talker, a listener, and a healer all at the same time -- exactly why I had gone into medicine.
When I returned to New York, I still thought eating disorder patients were rare, something that in ordinary practice I would encounter only occasionally. I was wrong -- the epidemic of eating disorders was just beginning to escalate.As part of my medical education arrangements, I had to do three years of military service. I was sent to Frankfurt, Germany, to run a pediatric/adolescent medicine program for military families at the large army base there. While I was there, I developed a comprehensive health-care program called the Youth Health Center. The three years I spent working with these adolescents really opened my eyes. The pressures they faced -- drugs, alcohol, sex, family breakups, fears for parents sent into danger -- were way beyond anything I had faced growing up. What I discovered from the Youth Health Center was the importance of being open-minded and nonjudgmental. I also learned how a transitional setting within the community could create a place where patients could gradually move from a hospital setting back to an independent life.
I took the lessons from Frankfurt back to New York with me. It was 1975 and I was now the chief of adolescent medicine at Brookdale University Hospital and Medical Center -- a primary affiliate of the New York University Medical Center at the time. We were pioneering the whole concept of adolescent medicine.
I began to get referrals for young patients with eating disorders, and soon I was admitting new eating disorder patients. By 1980 the numbers had increased so dramatically that we had to expand the inpatient adolescent division to incorporate the treatment of acute eating disorders.
Suddenly eating disorders were a major topic in adolescent medicine. Papers started appearing in professional journals. Hilde Bruch's groundbreaking book The Golden Cage appeared in 1978, and then the floodgates of popular books, magazine articles, TV shows, movies, and more opened. Anorexia and bulimia were hot topics. The problem, from my point of view, was that everything I was reading in the professional literature, everything I was hearing at medical conferences, seemed to differ from what I was observing with my own patients. The early experts were saying eating disorders were rooted in the external struggle for control between parent and child. They were saying girls became anorexic as a way to avoid their own sexuality. They were saying eating disorders were rooted in childhood trauma.
If the causes of eating disorders were confusing, the treatment recommendations were even more complicated. We all had a pretty good idea of how to deal with the medical issues of severely malnourished patients, but beyond that, the approaches were all over the place, with advocates for each claiming they had the right answer.
I kept reading all the material and going to all the conferences, and I kept trying to apply the latest analytic approaches to my patients, but they seldom worked. Following the most authoritative thinking of the time, we started to use a behavioral program. Eating disorder patients were admitted to the hospital and put in a restrictive environment. The more they cooperated and gained weight, the more specific privileges were returned to them. The approach seemed to work well -- patients quickly caught on to the system, complied with the routine, and gained enough weight to be discharged. At first, everyone -- doctors, nurses, parents, patients -- was extremely hopeful. But then we started to have repeat customers. Adolescents who had been discharged at reasonable weights were being readmitted, sometimes just a few months later, dangerously underweight again. It soon became clear to me that they had gained weight just to comply with the program. Once they were out of the hospital and back into their community, the symptoms quickly returned. Not only was the behavioral approach not working, I felt it was actually making things worse.
I kept falling back to the approach that seemed so natural to me: just talking and listening to these patients. They opened up to me and began to share the things that really interested them—the things that told them who they really were. Somehow, this method helped them begin to let go of their eating disorders. I came to realize that for many of my patients, the eating disorder filled a huge identity void in their lives. By helping them discover something else—some passionate interest rooted in their own personalities and talents—to fill that void, we ultimately replaced the power of the eating disorder.I found that my patients responded best when I went in with an open mind, willing to do anything to help them. I tried to develop an individual relationship with each patient, to understand her distinct personality and to tailor the treatment to fit her individual needs. And the more I treated my patients as individuals, the more they became individuals.What seems to work best for my patients is an approach to therapy that combines three aspects: personal, interactive, and rational. In our sessions I'm not distant from my patients and I don't see them as just cases—they're real people, and I've found that they respond best when I reveal aspects of my personality to them. Our sessions are interactive. The rational aspect of therapy is crucial. Eating disorder patients generally can't see themselves clearly—they need a therapist's help to see the reality of their condition and to grasp the ways out of it.
I call this approach personal interactive rational therapy, or PIRT for short. PIRT is based on the insights I've gained from years of experience in treating eating disorders. PIRT provides a framework for successful treatment. I know from my own patients and those of my colleagues that patients get better when they develop a strong personal relationship with the therapist, based on mutual openness, trust, and respect.
By the 1980s, as the eating disorder epidemic grew and the media became more interested, I felt I had something to add to the existing literature on eating disorders. In 1987 I co-authored a book about anorexia and bulimia, Dying to Be Thin, that received a great deal of national recognition. And by the 1990s, when the eating disorder epidemic had become even worse, I started to get calls from reporters and talk show producers for interviews about this expanding epidemic. Soon I was on television on a regular basis and getting constant calls from reporters—a demand that continues to this day.
In my media appearances I try not to exploit individuals with eating disorders but rather to educate our society about the importance of prevention, awareness, and treatment. I have been a guest expert on shows such as The Oprah Winfrey Show, Good Morning America, the Today show, CNN News, 48 Hours, 60 Minutes, and more. In every interview, on every TV show, in every publication, I talk about the role of identity and a strong sense of self in preventing eating disorders. I talk about how a passion in life can replace the eating disorder and fill the inner void it once occupied. And I talk about how individuals with eating disorders, even long-standing ones, can be helped.
In 2005, after thirty years at Brookdale University Hospital and Medical Center, the time had come to step down. Today I'm a clinical assistant professor at New York University Medical Center and Bellevue Hospital Center. I continue my mission of helping to end eating disorders through my well-established private practice in Manhattan and Long Island, New York. Through the stories and insights my patients have given me over the years, I hope to share my philosophy and treatment approach as an eating disorder specialist.
ONE
Identifying the Disorder
In my thirty-five-plus years of practice, only one patient has ever told me she wanted to have an eating disorder. Only one person has walked through my door and said, "I made a conscious decision to become anorexic." Every other patient I've ever treated found herself unintentionally ensnared by an eating disorder, the result of any number of influences, decisions, and circumstances.
The desire for weight loss is the most common starting point for an eating disorder. It can begin innocently enough, with the desire to lose weight and look better. But for some people the physical changes that weight loss brings about are so seductive, the praise they receive from others is so gratifying, that they feel compelled to further diet. Changes in brain chemistry brought about by weight loss can also reinforce these limits, and, as if something is set in motion, an eating disorder is soon in place. Other factors may also come into play. Having an illness that leads to appetite loss and weight loss may start an eating disorder. A significant change in circumstances, such as a divorce, a death in the family, or a move, can make an individual vulnerable. Positive events such as a wedding or a new job may also be responsible. Sometimes, people will restrict (or, in the opposite direction, binge) in an attempt to combat anxiety, and possibly depression. And sometimes, even an offhand remark like "You've put on a few pounds" can be enough to get someone started down the road to an eating disorder. Whatever the trigger, it's important to know that eating disorders do not come about by choice.
How Does It Start?
Ironically, the eating disorder, which can represent a profound threat to a person's health, can often be traced back to a desire at first to become healthier, a desire that finds expression in a weight-loss diet and sometimes exercise. Most people who decide to go on a diet end up following a script that has a predictable ending. The dieter will adhere to the advice given in just about every diet book—restrict food intake and exercise more—and that generally works for about the first month or so. The first couple of weeks are very gratifying because most people will lose several pounds quickly. The next couple of weeks are harder—the weight comes off more slowly, and the hunger pains and sense of deprivation grow. By the end of the month, the dieter has lost perhaps ten pounds, but weight loss has stalled. At that point the denials and rationalizations begin: "One cookie won't make a difference." "I've been so good I deserve this treat." "I'll take a break today and be good tomorrow." The diet and exercise stop. The lost weight gradually returns.
For some people, going on a weight-loss diet seems to trigger something in them. They find a deep satisfaction in restriction and a deep gratification in weight loss. For these people, the sense of accomplishment that comes with weight loss, along with the praise and admiration they receive as a result, gives them a new identity, the identity of someone who's really good at being disciplined and losing weight.
For others, however, the physical changes in the body offer concrete evidence that efforts are paying off. This is motivating, as is the realization that the cause and effect of diet and weight loss are straightforward in a way that little else is. But as she restricts her diet more and more, as she loses more and more weight, any tendencies the person might have toward obsessive-compulsive behavior and perfectionism, two common characteristics of individuals with eating disorders, have an opportunity to really blossom. And as she loses more and more weight, she discovers something else. Weight loss feels good because it helps to calm the high level of anxiety that is another common characteristic of individuals with eating disorders. Being in a state of semi-starvation causes changes in the metabolism and brain chemistry that reinforce the restricting behavior by creating a natural high. Further reinforcement comes from family and friends, especially peers. They're all saying, "Wow, you look great" and "I really admire all your hard work." Now the person is not only feeling the high, but also getting all this reinforcement. It appears to be a win-win situation, but the end result is a serious eating disorder.
Defining the Disorder
By the time a patient ends up in my office, the eating disorder has generally been in place for months, if not years. It can take that long for a parent, spouse, or friend to realize that an eating disorder has taken root. It can take weeks or even months longer to convince the patient that treatment is needed, and then it can take weeks, months, or even years to find the right sort of treatment. In the meantime, of course, the eating disorder only grows stronger, as does the damage it causes.
The sooner an eating disorder is recognized, the easier it is to treat the problem. I know from experience, however, that individuals with eating disorders become very adept at hiding them. Even specialists can fail to see an eating disorder when it first presents itself. Definitions are a big part of the problem in detecting these disorders early on. At what point does being on a diet or eating too much become classified as a disorder? At what point does the desire for exercise cross over into an obsession? At what point does the act of taking refuge in "comfort food" turn into a binge eating disorder? It's a fine line, and often the patient is well across it before anyone notices.
Anorexia Nervosa
I recently started seeing a patient named Tessa. She's thirty-five and has a long treatment history. Before coming to see me, she had been treated by no less than eight different physicians and therapists specializing in eating disorders. According to Tessa, not one had the same eating disorder diagnosis for her and none were very effective in treating her. She was willing to give treatment one last try, which was why she was in my office.At our first session, Tessa shared some of her early history. She was diagnosed with anorexia nervosa when she was fourteen, when she restricted her diet so much that she lost a significant amount of weight and stopped having her period. At that point, Tessa had all the major behavior patterns of the disease known as anorexia nervosa, as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association. These are the standard guidelines used by therapists, physicians, psychiatrists, psychologists, treatment programs, and others to define eating disorders. They're not perfect, but they're widely accepted as a workable way to ensure that everyone is defining the various eating disorders in more or less the same way.In high school, Tessa showed all the classic signs of anorexia. She restricted her food intake so much that she had severe weight loss that was greater than 15 percent of the normal body weight for someone of her age and height. (Older definitions of anorexia nervosa said the weight loss had to be 25 percent or more—we're making some progress in diagnosing the disorder sooner.)
The DSM provides the standard guidelines used by therapists, physicians, psychiatrists, psychologists, treatment programs, and others to define eating disorders. They're not perfect, but they're widely accepted as a workable way to ensure that everyone is defining the various eating disorders in more or less the same way.At fourteen, Tessa had starved herself down to a severely anorexic weight. Painfully thin, she also had many of the physical problems caused by severe weight loss: fatigue, hair loss, brittle nails, black circles under her eyes, low blood pressure, a slowed heart rate, easy bruising, thinning bones (osteopenia), and low body temperature (hypothermia). As well, she had many of the emotional and physical complications: severe mood swings, depression, generalized aches and pains, agitation and anxiety, and sleep disturbances. Tessa also had another very serious psychological problem: frequent thoughts of suicide. Although she never acted on them, her suicidal thoughts were extremely upsetting and unnerving.
Like everyone with anorexia, Tessa absolutely refused to gain weight. No amount of discussion, persuasion, bribing, yelling, or threatening could make her eat more. Tessa's family, her family doctor, and her therapist tried everything but couldn't get through to her. She also had a seriously distorted body image. (People with anorexia usually see themselves as fat even when they are clearly very underweight. In addition, they usually deny how serious their low weight is.) Tessa was convinced she was fat even when her weight did not reflect that image.
Tessa also had another important sign that applies to females with anorexia nervosa: She stopped having menstrual periods. A female is diagnosed anorexic if she's missed three consecutive periods because her body weight is too low. Tessa went almost two years without having a period.
The formal definition of anorexia nervosa doesn't give any age guidelines. Anorexia generally starts between the ages of about eleven and fourteen, but I've seen anorexic patients in their forties and fifties. I've even seen them as young as five. Anorexia is often thought of as a disease of teenaged girls, but today more and more young men and older women are being diagnosed with it as well as other eating disorders. The face of anorexia—and of all eating disorders—has changed in recent years to include a broader range of ages, more men, and more minority group members.
Within the anorexia nervosa diagnosis, there are two types: restricting types and binge-eating/purging types. Restricting types will rigidly limit their intake to small and smaller amounts of food. Binge-eating/purging types will usually restrict during the day, followed by eating large amounts of food in binges in the evening, then purging by vomiting or misusing laxatives and diuretics. (The binge-eating/purging type of anorexia differs from bulimia in that the binge and purge are not planned and the individual can still restrict food intake.) Tessa was classified as the restricting type of anorexic.
Tessa stayed anorexic until she was a senior in high school, when she finally began to eat more and gain weight. This is not an uncommon pattern. Young women with anorexia do sometimes seem to just get over it, but that's often an illusion. In many cases, what has really happened is that the eating disorder has simply taken another form. Tessa ate more and gained weight, but because she was afraid her weight gain would get out of control, she started running. That quickly grew into an obsession, and she advanced rapidly from short distances to marathons. Her weight dropped back to her anorexic levels as her running became more obsessive and ritualistic.