Volume 16, Number 3
Straight and Narrow for the Narrow
For eating disorders, clear boundaries, retraining do the job.
Talk with psychiatrist Angela Guarda an hour and you can see the approach she's developed for eating disorders is a lot like her: intelligent and quick to translate common sense into action.
The Hopkins program
she administers is a novel mix of tactics to reinforce normal behavior and
to make patients aware of the flawed thinking that powers their dieting.
Much of it was adopted primarily because it works. In a recent study she and colleagues did on 117 patients who completed the program-many had failed other approaches-weight gain was faster than elsewhere in the country. "A fast gain translates into a higher likelihood patients will reach the healthy weight goal necessary for recovery," says Guarda. Also, the study's initial follow-up a few months after discharge showed most patients still maintaining weight, still on recovery's road.
The good results, in part, stem from recognizing how different eating disorders are from most psychiatric illness. "In anorexia nervosa and bulimia, patients are ambivalent toward treatment," she explains. That's unlike, say, depression or obsessive-compulsive disorder, where patients feel miserable and ache to get well. "But with eating disorders, there's something rewarding," says Guarda. "Patients fear gaining weight and typically don't resist intrusive thoughts about food or weight, which can take up to 80 percent of waking time. At some level they like their illness. 'Anorexia's my identity,' they say.
"In a sense, the two disorders are addictions to dieting. And, like drug addiction, you treat them by helping to right unhealthy behaviors.
"Many programs work to clarify underlying psychological issues. Patients like that. They prefer to talk about their motivations for dieting," Guarda explains. "But we've found understanding motivation, by itself, won't bring about change. You change behavior first, then understanding follows."
Chad Davis, 22, is an earnest man who works in his father-in-law's jewelry store in Georgia. He has forearms barely broader than the bones within and he seems slightly surprised by his anorexia nervosa, like it's happening to someone else. Like many, the illness crept up on him. "I never wanted to be skinny. I just wanted to be in shape." Davis began running to firm up. But at some point, he began running more and eating less. "It just happened." In three years, he was exercising hours daily, fueled by a single bowl of cereal and ephedrine-laced tea. A local psychiatrist helped briefly, but then came a relapse.
When he came to Hopkins this winter, Davis, at 5'7", weighed 85 pounds. His temperature hovered at 94 degrees. Closely monitored, he was briefly on an IV. "But right off, they start you eating small meals," he says. "Then you work up to larger ones."
Initially Davis hated the way nurses sit with patients, prompting them to finish meals. "It felt like kindergarten." Worse, he says, his stomach hurt for a week from the unaccustomed food intake. "Nobody told me it'd be like that." But then the program's logic sank in. "I see now I had to go through it all," he says after three weeks. "I couldn't have done it on my own." Guarda confirms Davis' feelings as typical. "People become more accepting, more motivated as they progress."
She emphasizes that changing attitudes is key. Patients initially, for example, divide food into two groups: safe vs. risky. "But the program teaches no food is inherently bad for you, that it's the combination, amount and regularity of eating that's important." Patients go on a food exchange program similar to one diabetics use. As they learn to choose and apportion food, the variety of foods they eat jumps. Davis found himself preparing meals. He grew to like the staff-led restaurant outings that strengthened right habits while they re-introduced social eating skills he'd lost in his food-shunning days.
The young man also began to label some of his thinking as pathological or, at least, distorted. When, at first, Davis hoped treatment would make him strong enough to return to his all-consuming exercise and dieting, "we helped him see that's a warped idea," says Guarda.
Part of what makes the program work is its heavy reliance on peer pressure. The hospital unit houses both teenagers and adults-something research shows works well. Living with people who know your motives, adds Guarda, is more likely than anything else to incite change. "When I heard others had stomach pangs when they first came," Davis says, "that went a long way to help me ride things out."
Unlike most places, Hopkins uses a "step-down" approach. Patients enter as inpatients, then, with progress, ease into a less-supervised partial-hospital setting. "Most programs do just the opposite," says Guarda, "They start with the day hospital. Yes, it's cheaper per day to do that, but we've shown that overall it can be more expensive in terms of needed treatment time."
Heidi Hallman, an attractive, articulate graduate student who has bulimia, emphatically agrees. "If I'd started outpatient, I know I'd have gone home in the evening and exercised, binged and purged. All that freedom at a critical time does you no good. You need the discipline imposed on you."
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