Complex Causes of Restrictive Type Eating Disorders
Dr. O’Melia is a Pediatrician and Child Psychiatrist, who serves at Eating Recovery Center in the dual roles of Chief Medical Officer and Chief Clinical Officer, overseeing the therapeutic and medical excellence of our programs. Dr. O’Melia is a renowned expert in the complex causation, care and treatment of eating disorders. The following presentation will provide you the opportunity to learn about the unique interplay of the variables that contribute to causation of restrictive type eating disorders, as well as the processes necessary for recovery.
Anne Marie O'Melia:
I'm Anne Marie O'Melia. I'm a Pediatrician and Child Psychiatrist and I have for my whole professional career been very interested in medically-complicated psychiatric patients and psychiatrically-complicated medical patients, especially kids. And where do eating disorders live? They live right there, right? Right in the middle. There are a lot of medical issues associated with this psychiatric illness. And so, I've been fascinated by the different presentations and also the sameness of the presentations for many years. Also, before I became a Physician, I was a Psychologist. So, I was already taking care of some patients with eating disorders before I went to med school, and then it allowed me to kind of help direct my interests.
So, I work here as the Chief Medical Officer. It doesn't say this on the slide, but I'm also the Chief Clinical Officer. So, I oversee the psychotherapeutic excellence in our programs, and then I also oversee the medical stabilization and psychiatric excellence at ERC.
So, I'm really happy to have you all here today. I'm actually just going to start with a fairly low-key demonstration and explanation of how I do an initial consultation when I first meet a patient who has been diagnosed with an eating disorder or might have an eating disorder. Often, the patient is the last to know that they have an eating disorder or at least, the last to really accept that this is what's happening to them. So, I will start a consultation and I do this with families. I do this with kids. I do this with adults. And I'll say, "I know a lot about eating disorders and you know a lot about you or your loved one. Let me talk about eating disorders. And in particular, this slide is going to represent restricting type eating disorders. And as I talk, I want you to think about how much of this applies to you and what has happened to you. So, here we go."
So I say that "Eating disorders don't just happen to anybody. They happen to particular types of people most of the time."Is this better?"
Anne Marie O'Melia:
It scares me to talk in this but, you guys were looking at me again, like... You got to raise your hand now. All right. So, eating disorders don't happen to just anybody. They usually happen in particular types of people, people who have just the right kind of genetics, just the right temperament, walking around this Earth. And most of the time, people before they ever know they're eating disordered, are anxious, kind of high strung kind of people. They're also a little obsessional. That doesn't mean they have obsessive compulsive disorder, but it does mean that they tend to have things roll around in their head for a while and then, it's hard for them to shift gears and switch to something else. So often, they get a little stuck until something's done. It's hard for them to not think about it and it has to be done right.
Before they become patients, these people tend to be kind of perfectionistic. They're also pretty routine-oriented. These are usually kids who like to have kind of a schedule. They like checklists. They like to know what is going to come next. They sometimes don't like to if you take a different route on the way home, because it wasn't expected. They don't like change much. They don't like surprises. They're not gamblers. They like to follow the rules. And they really like for everyone else to follow the rules too.
Okay. So, they like to follow the rules and they like us to follow the rules. They like to know what to expect and how you people should behave. They tend to be very risk averse and breadth sensitive. So, the same level of risk might feel much harder for these patients to process. Often as kids, they have low expressed emotion. They don't have a lot of tantrums. They usually move along with things. They don't cause a lot of commotion. They don't like when people argue. They're generally pretty well liked. They're nice kids. It's actually a risk factor for eating disorders is being nice. They're nice kids. It's actually a risk factor for developing eating disorders, to be nice. It's an actual risk factor.
They tend to be pretty successful. They don't actually have higher IQs than the general population. Our patients work very, very hard and they just take to things. So despite being pretty well liked and very successful, they also often have pretty low self-esteem. So that's what these kids look like before this thing comes up: so, nice kids who don't like a lot of change, little bit anxious and a little high strung. They get stressed out. You're next. All right. They get stressed out. It could be absolutely normal stress. It could be a culture change. This could happen because I moved from Elementary to Middle School. I had things on lockdown. I knew just what to do in Elementary School. I knew how to behave. I knew my teachers; they knew me. I was successful. Now, I moved to Middle School and the rules were all changed. Socially, academically, it's a whole different set of expectations. I mean, getting into college. Again, a normal stress, but it's still a stress.
It could be a physical change that causes the stress. Puberty is actually pretty stressful for people who don't like change and who don't like it when they don't know what's going to happen next. It could be a first pregnancy, or maybe if they get sick. Maybe they have gall bladder issues. Maybe it's stomach problems. Maybe they just got over mono and they get off track. That's very stressful for these patients.
It could be a relationship change. Again, it doesn't have to be something that would necessarily devastate somebody, but it's a stress. Parents get divorced, a friend moves away, or it could be a real trauma. Our patients have a higher incidence of adverse childhood events. They are more likely to have bullying, assaults, abuse and they are more sensitive to the effects of negative statements. So what one kid might see as bullying, another kid might as is teasing. These kids are over sensitive to negative interactions and they take it much more to heart.
So, this is an anxious kid who likes to know what's happening next. Change happens, they get stressed out, what happens to their anxiety? It goes up. What happens to their mood? It goes down. They get upset. They get cranky and irritable. So so far, we have some ingredients that help us understand some of the biologic perspectives.
So, the traits they described at beginning are temperamental traits. These are not chosen by any of us. This is just the way we are wired from her. Anybody who's raised several kids or even just two kids can tell you, that's just the way we came. These are their temperamental traits. So, I did not do anything to make them work this hard. I didn't do anything to make them follow these rules. This is the way they were born. And then, I have another kid who came out completely different, a different temperament. So that's a biologic risk factor.
It's also genetic risk factors. Eating disorders actually have just as high inheritability risk. That means the risk of developing an eating disorder just based on inherent genetics are just as high as for anything else, any other mental illness. So, it's in the 60 to 70% range, 60 to 70% of the risk of developing an eating disorder is actually just contained in your genes, much like depression, bipolar disorder, any of the other mental illnesses. I actually have a very, very strong family history of breast cancer. So whenever I go to my primary care provider, she's asking, "When was your last mammogram? We've genetically tested all these things." The inheritability risk for breast cancer is 27&, but none of us really wonder about whether breast cancer has a lot of genetic risk, but we don't actually consider eating disorders... view eating disorders in the same way.
So, most people who develop eating disorders usually have some family member somewhere that had an eating disorder. It doesn't necessarily mean it was mom, dad, or a sister, but it is something that was wired in their genes in some way. But the genes don't necessarily be clicked on until it has the right epigenetic events, so things in the environment will put this gene into place.
So, we've got temperamental, biologic risk factors. We've got genetic risk factors. We talked about some of the psychological stresses, things that can happen in them. So, how about the social things that can click this thing on? What in our culture might actually reinforce the problem, the onset of this illness? Media and connections with what our cultural values are to be shared in the media, right? And so, we've got biological risk factors, psychologic risk factors, and now the social impact. In general, are we live in culture that values independence. We value low expressed emotion. We actually don't like people screaming, yelling, and whining much, right? And if a teenager started to get pretty anxious or pretty depressed or a young adult, what is our cultural solution to that? What would Dr. Oz say to do? He would say, "Get control of yourself." Right? He would say, "Be healthy. Start exercising." Right?
So, the next risk factor is actually not necessarily even a diet, but these are kids who say, "I want to get healthy. I'm feeling like my life is out of control and I want to get healthy." Nobody says, "I'd like to develop an eating disorder." But they say, "I want to get healthy." So they start by saying, "I need to start running three times a week." Or, "I'm going to cut out junk food." Or, "I'm going to give up chocolate for Lent." Or all sorts of things like that. These are all absolutely culturally sanctioned and a 100% normal. Is there anyone in this room who actually hasn't said, "I'm going to change my nutrition plan." Or, "I'm going to start exercising." Everybody's done it at some point, right? It's a 100% normal. And these kids are just at higher risk of having this really have a different impact on their brain.
So, these are kids who like routine. They like control. They get stressed out. They say, "I know how I'll get control. I'll get healthy." And they lose some of the weight. Very often, they weren't even kids that needed to lose weight, but they do lose weight. And then, our culture goes, "Wow, good for you." Now for most of us, when we go on a diet and we lose weight, does that relieve her anxiety and improve her mood? It actually doesn't. Most of us get pretty cranky, right? Irritable. And most of us quickly go off that diet. We regain all that weight. Plus, we actually usually do regain plus about 10% more. That's what the impact of diets are.
But for people who have just the right combination of genetics, temperament, psychological profile, the way they solve problems, and then also the social influence, what happens is it totally works. Their anxiety goes down and their mood improves. So, it's working and it makes perfect sense. We can understand why people would do it. They're eating less, they're exercising more and they feel better, right? So, this always starts as a system that says, "Follow these rules and you'll feel better." And nothing seems weird at all.
But then, and this is where the kids can usually tell me when their view of food shifts, the balance of power shifts, and then clicks on to, "Follow these rules and you'll feel better." Now the balance shifts, and it's now, "You follow these rules or else." Right? And they start doing more and more things. They start actually shifting their value, shifting the perspective in order to follow the rules and they become obsessed with these rules.
So, here we are. "Follow these rules and you'll feel better." It works. And then, my highly technical scientific term that I use is click. There are true neuro-biologic changes that happen in the brain. Something clicks. It's like the brain gets hijacked and now it becomes, "You follow these rules or else." Rules and rituals become a huge part of what people are thinking about. I'll ask a patient, "What percentage of your thoughts are about weight, shape, food, appearance?" What number do you think they often give me? Most of them, right? Yeah. Very high number. They become preoccupied with thoughts about weight, shape, food, appearance.
They engage in social withdrawal. So it's not just that they lose interest in being in relationships and other activities, but other people actually start to lose interest in them, right? So, people pull away from them and they start narrowing their focus of social activities. They can't go anywhere that food is happening, right? And they're not that fun to be around when 97% of their thoughts are about, "I wonder if I should eat that." Or planning what they can or can't eat. And so, they lose support and they pull away. So, eating disorders are disorders of isolation. And it's one of the reasons it's really so important for us all to come together and talk about this. And it's one reason that it's important to treat eating disorders within a group context because they are so isolated.
And then, the last thing up here is the weirdest thing, weirdest part of the whole thing, is that everyone can see it except the person that it's happening to. And they really can't. They have a distorted perception of their body. I mean, they'll be sitting in a hospital bed in Telemetry, very underweight, and they'll be saying, "It's not that bad. Maybe I could gain a few pounds." But they're terrified of what actually needs to happen to get healthy, right? What's the thing that needs to happen to get healthy? They've got to boss back these rules. They've got to fight these ritual things. They have to do the opposite of what the brain is demanding that they do.
But that's not the way it goes at first. At first, it actually starts to feel worse and worse. It started with, "Follow these rules and you'll feel better." And he did. And then, "You follow these rules or else you're disgusting, or else you're bad, or else you're weak." And now the problem is, that your anxiety is worse than it ever was, right? And your mood is awful. So, last week it worked to eat a banana and toast for every breakfast and to run three times a week. "My anxiety is very, very high. I guess I need to up that. So now, I can only eat the banana for breakfast and now, I've got to run five times a week." And that does work for a little while, that the anxiety comes down. But then click, it goes back in a little tighter, rules, rules, rules, anxiety goes up. "We got to have new rules."
Many of you will notice that once a rule changes, it's very rare for it to change back. Once that toast has gone from breakfast, it's never coming back on its own. The rules become sacred and they become a huge focus. People become obsessed with them and it will just click in tighter and tighter and tighter and tighter rules all the way around until the person truly dies from this. That's what the natural course of this is. Their brain has truly been hijacked. Their brain really won't let them eat.
And so, the treatment is something quite simple, right? It's food. Right? We actually have to feed the underweight person. And so, nutritional restoration it's just what's needed. It's what the brain will not let people do. Their brain is saying, "It's disgusting. It's wrong." But without nutritional restoration, none of rest of the stuff that we do actually matters, right? It's not the only thing that matters, but nobody has ever recovered from anorexia while they were underweight, not one time. So, it has to be done. And while we're doing that part, we also need to address temperament.
So, we go back and we help people understand, what were the risk factors for developing this? We're not asking you to change your temperament, we're asking you to understand it and how do you use it to actually get help. We ask people to go back and learn about their stress history. What were my coping strategies at the time? How would I like to learn new coping strategies for stress? Family dynamics are explored. We never say families cause eating disorders, ever. They don't. It's impossible. But also sometimes, family dynamics have to change in order to support recovery. So, it doesn't mean anyone did anything wrong, but it does mean sometimes, we have to actually shift some of our interactions and some of our styles in order for recovery to happen.
So, did that sound familiar to anybody?
Anne Marie O'Melia:
Yeah? All right. So, what happens if that first time through, all right, so we recognize it. We say this is anorexia or this is a restrictive-type eating disorder and we get them out, do the nutritional restoration. We go back, we teach them new coping strategies, they understand each other, and they get better, first time through. That'd be pretty good, right? What happens if it doesn't happen that way?
So some of these things start to change, and that's one of the ways that you help patients understand that this change has happened because of your eating disorder, that these changes are happening, they don't actually reflect your core temperament and your core values. So, it goes on long enough. So, there's people who were rule followers, sometimes they're not such rule followers anymore, especially when it comes to their eating disorder, right? So, the fact that they are giving up something that was so important to them, these patients often would never lie or cheat and steal about anything except their eating disorder, and that helps us help them understand, "This isn't you." Right? You have been hijacked.
Risk averse, right? So these people did not take a lot of chances. They were not the kind of people who jumped out of buildings or out of airplanes. Now, they're living every day with a fairly dangerous problem that they're very unable to actually take care of or fight back at. Low expressed emotion. Did anyone to see their loved one change with regard to how much they argue? Yeah. They become willing to do almost anything, to sacrifice almost anything to protect their illness, right? I mean, these are kids who have never broken a rule, straight A student, cussing out their doctor, right? And it's like, "Where did my kid go?" So, low expressed emotion goes away. Conflict avoidance also, especially when it's related to the eating disorder. Well liked, they actually pull more and more way and it gets harder and harder to relate to these patients. They're not as successful in school. They start to give up their goals. The eating disorder starts to get in the way of their values. Their low self-esteem stays though, right?
So, their identity now becomes fused with the eating disorder. It gets harder and harder for them to tell the difference between what is me and what is my eating disorder? Even though we can still remember who they were before the eating disorder, it's harder and harder for them to see the difference.
So, it started off as a health plan. Now, it becomes pretty locked in the abnormal eating habits, a lot of food-related behaviors become fueled by avoidance. It's emotional avoidance. Another trait of these patients is, they tend to make decisions based on avoiding discomfort rather than seeking something really great. Is that anything you guys have noticed in some of your loved ones? So, avoiding food right now because they're just so uncomfortable to break the rules. But it's the same almost as often, my patients have very good grades, but if I ask them, "Why do you get all A's? Why are your grades so good?" They say, "Because an A feels great." Or, "Because a B would feel so terrible." It's mostly that they're avoiding the B rather than absolutely celebrating and having a great time or popping champagne when they get the A, right? So, they're making decisions to avoid discomfort, which is why sometimes we have to make the decisions for them about the food, because they have a very difficult time pushing back when they know they're going to feel really uncomfortable.
And there is an addiction-like quality to it, right? It gets harder and harder for them to do the harder thing. And there is a part of it that they are actually feeling good. They're feeling calmer from the pulls and from the state of starvation. The weight loss that they had had, actually now, they have a chronic low weight with a lot of the medical consequences of it. Being the anxiety and depression, they become stuck in a state of emotional avoidance.
This neuro-biological change, this click that hijacks people, it actually becomes, the longer it goes on, the more it gets clicked in. So, one of the things we know is that neurons that fire together wire together. The longer they go on, the longer it takes to unwire. Let me give you an example. Everybody tell yourself, "Am I right handed or left handed?" Just put that in your head. Okay. I'm right handed. So, let's imagine that I developed a strange neurologic problem, that everything I wrote with my right hand was a lie. What would I do? I meant to write true. I'd write false. I meant to write blue. I'd write green. What would we do?
Start to use the other hand.
Anne Marie O'Melia:
That's what I would do, right? I would write with my left hand. How would it feel?
Anne Marie O'Melia:
Completely wrong, uncomfortable, right? It would feel awful. It would be sloppy. It would be completely unnatural, right? So, I have been writing with my right hand for so long that to start to write with my left hand would have to be very deliberate. It would be sloppy. It would be embarrassing. It would feel wrong. And every time I went to pick up a pen, I'd probably try to pick it up with my right hand and have to fight with myself to get it over here, right? It wouldn't feel natural at all, right? And so, as our patients become fused with the eating disorder, it feels correct because those neurons have been firing the other noun for some time. And the longer it goes on, the harder it is to actually rewire. But it can be done, right? I mean, an older person. If I really decided I was going to learn to write with my left hand, I could do it, but it would take me a long time and it would feel wrong every time I tried until I got better and better and better. And eventually, it would start to be okay. And that's really what we're asking our patients to do. We're asking them to truly rewire their brain by doing the opposite thing that feels natural to them.
So they were preoccupied, but now they have extreme cognitive rigidity the longer this goes on, right? They now have... back to social withdrawal, but they're really isolated now. And the longer it goes on, we have worse and worse treatment responsivity, right? It doesn't mean people can't get well. I see people get well after 30, 40 years of being very stuck in anorexia. Recovery is always possible, but we should know that the longer it goes on, the harder it becomes to treat. And so, we have to use every opportunity that we have to actually take care of it.
Did that resonate or fit with anybody's personal story?
Anne Marie O'Melia:
Okay. I'd like to try to use this to actually talk to my patients. Because most of them say, "Oh, yeah. That is exactly what happened to me." Because the eating disorder is sending the messages that "You're in control, and this is how to be successful." But when I can actually pull out a PowerPoint or just draw this thing out and say, "Well, this the way it usually goes." It takes some of that specialness away, right? "Well, this is the usual story. Which part of this actually happened to be you?" And they'll usually say, "Most of it." And so, "When it happens the same way each time, it's actually not something that is special to you. This is the way this very serious and life threatening mental illness presents. So, what do you want to be? You want to go back to, or return to the person that you were before this thing hijacked you? Or do you want to be controlled by this mental illness?" Simple questions like, "Well, I feel in control because I'm using"... Don't follow these rules if you're out of control. "I feel disgusting. I feel weak and lazy." I just ask people, "Which would be harder, to follow your meal plan or to follow the rules of the eating disorder?" And it's always, "Well, the eating disorder rules are easier now." Right? But they lie and tell me that's what's being in control. So, "Being in control, we follow our meal plan, and we boss those rules back and we regain control."