Eating Disorders News by Marcia Herrin and Nancy Matsumoto

Check it out online: Binge Eating Disorder Week

2013-05-25T15:33:57-07:00

Some of you may have read this post I wrote a while back, about the website, Beutiful, devoted to battling fashion-mediated body ideals and empowering individuals to make their own decisions about what is beautiful.

Now, site founder Patricia Colli is among the sponsors of an awareness campaign and week’s worth of special BED online events that will take place from May 27-31. The event, explains Colli, which includes live tweetchats, new website articles and other social media happenings, celebrates the inclusion of BED in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

On May 29 a live tweetchat will take place from 12 to 1 pm EST using the hashtag #BEDCHAT. Look for articles, newsletters, blog posts and tweets focusing on education, preventing weight bias and stigma, promoting positive body image and legislative activism, as well as information on where to find support. Hashtags will be #BEDWEEK, #DSM5, #BEDAWARENESS, #EATINGDISORDER and #ED, or check updates on the BED Week event Facebook page. For a link to the full week-long program click here.

I’ll be following along, and am looking forward to learning more about BED through these online happenings and postings.

One way to find a Good Nutritionist

2013-04-30T13:08:32-07:00

I am asked often by parents across the country for help in finding a local nutritionist who is an expert in eating disorders. A new organization of which I am a member, the International Federation of Eating Disorder Dietitians (IFEDD), provides just such a service. Parents and others can go to IFEDD website for a list of nutrition providers in the US and across the world.

I also suggest that parents ask their doctor and/or therapist for the names of good nutrtionists. Usually qualified and effective professionals are well known in their local communities.

Let me use this opportunity to tell you a little more about IFEDD. We lobby to increase insurance coverage for nutrition services which is a major problem in many states. IFEDD is also collecting published research on the effectiveness of eating disordered-specialized nutritionists. Nutritionists who belong to IFEDD can use these references when they make a case for insurance coverage for a dietitian in the treatment of a patient with an eating disorder.

One major problem in the nutrition field is that there is very little published on nutrition techniques in the treatment of eating disorders. IFEDD is working to remedy this by providing grad students to help busy clinicians set up research projects.

Nutritionist Marcia Herrin and Nancy Matsumoto, co-authors of The Parent’s Guide to Eating Disorders, Gūrze Books, Marcia is also author of the recently published Nutrition Counseling in the Treatment of Eating Disorders (Routledge, 2013).

Copyrighted by Marcia Herrin and Nancy Matsumoto.

Photoshopped Fashion Models: Let’s Get Wise to Them

2013-04-15T12:20:09-07:00

Recently, Marcia and I received an email from a college student writing a paper on the relationship between Photoshop and eating disorders. This is an ongoing discussion, and part of the larger issue of mass media’s depiction of unrealistic body types for both women and men and its effect on body image and self-esteem.

With Photoshop and other image-editing software, photo editors can touch up, manipulate, merge, blur and take all kinds of creative license, turning a fairly accurate likeness of a person into Barbie and Ken doll look-alikes.

One of the biggest issues we have with “Photoshopping” in fashion magazine is that editors don’t have to disclose its use. If Vogue photo layouts came with the equivalent of the surgeon general’s warning on cigarettes that might help.

Here are some of the questions we were asked, and our responses. Answers in the first person are all Marcia’s:

Q. Do manipulated images contribute to eating disorders?

A: I don't think anyone knows for sure. Very thin women have been used in ads long before Photoshop. Most people with eating disorders do acknowledge how images of beautiful thin women have affected them (me included).

Q. In what way are women affected by these altered images?

A: The images shape what our standards of beauty are, and obviously illustrate a societal ideal. If one is aiming to be the best in everything these images can encourage women to try to be as thin as possible. Society’s idea of absolute beauty hasn’t always been that of a sickly stick figure: take a look at this witty piece in London’s Daily Mail, “What if Boticelli had Photoshop?”

Q: Do Photoshopped images affect men?

A: My male patients tell me that pictures of male models and actors with sculpted, six-pack abs are very disturbing.

Q. Is there anything that can be done to limit the use of altered images?

A: A law passed in Israel in 2012, known as “The Photoshop Law” prohibits advertising or fashion media from employing models who fall below the World Health Organization’s standard for malnutrition (18.5 Body Mass Index), and also regulates the use of Photoshop in photographs.

No movement to pass such a law in the US has yet surfaced. At its 2011 annual meeting, the American Medical Association issued this fairly toothless statement warning the public that manipulated advertising images can result in “unrealistic expectations of appropriate body image,” especially among children and adolescents. The AMA also encouraged advertising associations to try to prevent body image problems and eating disorders by working with organizations concerned with child and adolescent health

Q. What do you think should be done to counter the negative effects caused by unrealistic manipulated photographs?

A: We support governmental action because the fashion industry has done next to nothing, and we like what Israel has done. Whether or not regulations are imposed, Americans are in a buyer beware situation. It’s important to talk to both adults and children about the fact that most of the fashion photos we see have likely been Photoshopped. We need to remind ourselves whether manipulated or not, these images should have no bearing on how we evaluate our bodies. They should have as much to do with our self-esteem and size and shape goals as do National Geographic photos of tropical fish; that is to say zero effect!

Recovery is a Healthy State, not Weight

2013-03-31T18:46:47-07:00

A question that comes up regularly in the eating disorder field is how to define recovery? Is it a maintaining a certain weight or BMI? It is abstaining from restriction, bingeing, purging, and over-exercise? Is it eating without fear and guilt? Is it accepting one’s body size and shape? It is self-esteem that is independent of size and shape? Of course it includes all of these factors. I like the idea of recovery defined as a Healthy State. I can’t take credit for this term. Rebecka Peebles, MD, my co-presenter on this topic at the Academy of Eating Disorders International Conference in Montreal in May, tells me that the concept of a "Healthy State, not Weight," was coined by Janet Treasure, MD and several British mothers whose daughters had anorexia. Professor Treasure, a psychiatrist at Guy’s Hospital, King's College London, is a leading figure in the field of eating disorders and the author of several books for parents that are very helpful. Rebecka also pointed me to Dr. Treasure’s unique educational project on youtube that includes a “lesson” on Healthy State, Not Weight and another lesson on how parents can help an eating disordered teen follow a food plan, Modeling Effective Parenting. You have to see these videos to believe them. Picture one-dimensional claymation? They really are educational and precious.

Marcia

Nutritionist Marcia Herrin and Nancy Matsumoto, co-authors of The Parent’s Guide to Eating Disorders, Gūrze Books. Marcia is also author the soon to be published Nutrition Counseling in the Treatment of Eating Disorders (September, 2012). Read more from Marcia and Nancy by clicking here.

Copyrighted by Marcia Herrin and Nancy Matsumoto

Life without Ed's Jenni Schaefer inspires Dartmouth (and me).

2013-03-18T18:59:39-07:00

Long time friend and ED activitist Jenni Schaefer, author of Life without Ed and Goodbye Ed, Hello Me, spoke at Dartmouth College last month. I joined many of my patients in the audience for an inspiring evening. I promised several who were not able to attend that I would write up my notes.

Jenni opened her presentation saying that she is proud to be a “living example of both the journey to freedom from an eating disorder and the rediscovery of self” and then she shared some of her personal recovery story from her book, Life Without Ed. Read more on Jenni’s website.

Jenni was born in Texas, and she recalls first feeling she wasn't thin enough at the age of 4, when she began to study dance. Jenni showed us her first little dance costume to make the point that her eating disorder gathered steam when she began to restrict food as a teenager to try to keep that "little girl's body." Jenni also told us about how difficult college was her. He life was organized around the belief that to be happy and successful, she had to be thin and be “unrelentingly perfect.” After being accepted into medical school, Jenni eating disorder worsened. Instead of going to med school, she took a leave and within the year began treatment with a therapist, nutritionist and a doctor beginning “a long slow recovery that changed my life.” 

Jenni told us, “Never, never, never give up!” She then quoted Amelia Earhart who said “The best way to do it, is to do it.” In treatment, Jenni learned that her eating disorder was not about the food, but, but food was the best medicine for recovery. “A starved brain cannot get better.” She remembers thinking that following a food plan would be impossible. She couldn’t picture eating on regular basis or responding normally to hunger and fullness. But when she just starting eating as her nutritionist directed her, the real emotional recovery began.

Jenni then stopped talking and drew a graph on the chalkboard similar to this clipart.

“This graph of ups and downs describes my recovery. I learned from every fall. I learned to recognize the lies ED told. I learned to say no. I learned I could go to bed with the covers over my head and that the bad feelings would pass without me acting on my eating disordered thoughts.” One of my patients was so taken by this imagery that she asked Jenni to include this graph when she autographed a copy, Life without Ed.

Jenni ended the evening with several songs and some insights from her second book, Goodbye Ed, Hello Me, about finding real joy and peace in life. "It's not just about food and weight," she says. "I'm here to help people to fall in love with life."

At lunch earlier in the day, Jenni told me about her new book, Almost Anorexic, due out this summer. Jenni’s co-author is eating disorder expert and Assistant Professor of Psychology in the Department of Psychiatry at Harvard (and Dartmouth grad) Jennifer J. Thomas, PhD. Almost Anorexic is written for an overlooked but prevalent segment of people who suffer from many of the key symptoms of an eating disorder but do not quite meet the full diagnostic criteria of one of the eating disorders. I know many people who fall into this category. They often feel that their situations aren’t bad enough to deserve treatment. Jenni wrote this book for you. Thank you, Jenni!

Copyrighted by Marcia Herrin and Nancy Matsumoto.

What Are You Avoiding? Adolescent and Parent Behaviors That Allow Anorexia to Thrive

2013-03-14T06:52:11-07:00

One often-overlooked aspect of recovery from adolescent anorexia is the need for both child and parent to shake off negative, established patterns of coping. For the adolescent, the illness can play the valuable role of masking or numbing feelings of fear, anxiety, low-self esteem, loneliness or boredom. It can also be away to avoid experiences that are threatening or scary: unwanted attention, new social situations or challenges of any type.

For parents, another form of avoidance can come in the form of accommodation: aiding a child in her ritualistic eating behaviors and self-starvation in order to avoid the immediate distress that results in opposing those behaviors.

These would be the parents who stock their fridge with non-fat foods, no-calorie lettuce, “acceptable” energy bars and other such staples, who avoid providing “challenging” foods in order to maintain calm in the home or because they can’t bear to see their child in any more anguish.

A group of researchers has devised a treatment called Acceptance-based Separated Family Treatment for Adolescent Anorexia Nervosa (ASFT), which they hope will help both parents and adolescents learn to replace their rigid and avoidant behaviors with more accepting, flexible behaviors driven by long-term values and goals.

One of these researchers, C. Alix Timko, PhD, explains that AFST is broadly based on a form of psychological treatment called Acceptance and Commitment Therapy (ACT). ACT itself is an increasing popular form of “acceptance-based” Cognitive Behavioral Therapy, one that interprets psychological problems as rooted in emotional and experiential avoidance.

A National Institute of Health-funded pilot project begun in 2008 yielded promising enough preliminary results to spur Dr. Timko and her colleages Rhonda M. Merwin, PhD and Nancy Zucker PhD, to continue their research, which they describe in this article in the latest edition of the Renfrew Center Foundation’s journal Perspectives.

AFST incorporates key concepts of Family Based Treatment (FBT), the current gold-standard approach to refeeding adolescent anorexia patients, but supplies a psychological component that FBT has heretofore not stressed. It involves 20 90-minute sessions of treatment spread over 24 weeks, divided evenly between adolescent and parents. For the first 16 sessions, adolescent and her or his parents are seen separately. Joint sessions are held during the last four every-other-week sessions.

Three phases of treatment take place. In the first, therapists prepare patient and parents for the tough work ahead, stressing the importance of being willing to experience some difficult thoughts and feelings. Parents are encouraged to recognize their own importance as healthy role models, and are given a workbook with information on authoritative parenting, the psychological aspects of eating disorders and behavior management. All this happens as they are taking control of their child’s eating according to FBT protocol.

In the next phase, the therapist conducts a “functional analysis,” during which the patient comes to see how the disorder has both helped and harmed her. Parents are encouraged to think about how they may have over- or under-reacted to the disorder, and how they can improve their lives in other areas to make them better caretakers. As part of this phase, explains Dr. Timko, therapists create a timeline with the adolescent to help him visually graph factors that may help maintain the disorder.

“We ask, ‘When is the eating disorder loud?’ ‘When do you have urge to exercise or restrict?’ ‘What were your thoughts and feelings in this situation?’ Throughout the course we look for patterns,” explains Dr. Timko.

The third phase is the heart of AFST, when the real work of changing attitudes and behaviors takes place. The catch-words “open,” “centered,” and “engaged” are used to help patient and parents accept difficult thoughts and feelings nonjudgmentally, and to distance themselves from these subjective experiences. The joint parent-adolescent sessions focus on communication and relapse prevention.

Drs. Timko, Merwin and Zucker plan to eventually create a treatment manual for therapists based on AFST. For now, though, they’re collecting more data on its effectiveness compared to FBT. A manualized version of Dr. Zucker’s parent skills program Off the Cuff program—which I wrote about in this blog post, is, however, available from Gürze Books.

Marcia Goes Hollywood

2013-03-06T19:48:16-08:00

I had the pleasure of working with Abbey Stone, celebrity editor for Hollywood.com, on an e-article challenging celebrities to talk differently about their eating disorder history. Instead of the typical celebrity story serving as a guidebook on how to develop an eating disorder, Abbey wants A-listers to focus on how they got help and to describe their path to recovery. Check it out at

CELEBRITY EATING DISORDER CONFESSIONS: INSPIRING OR DANGEROUS?

Marcia

Nutritionist Marcia Herrin and Nancy Matsumoto, co-authors of The Parent’s Guide to Eating Disorders, Gūrze Books. Marcia is also author Nutrition Counseling in the Treatment of Eating Disorders (2013). Read more from Marcia and Nancy by clicking here.

Copyrighted by Marcia Herrin and Nancy Matsumoto

Raising Self-Esteem and Teaching New Coping Mechanisms

2013-02-04T08:49:46-08:00

After writing a few posts on the intricacies of complex anorexia care, it seems fitting to talk about a more global concern: the poor body image and low self-esteem that go hand-in-hand with an eating disorder.

In Unlocking the Mysteries of Eating Disorders: A Life-Saving Guide to Your Child's Treatment and Recovery, written by David Herzog, MD and Debra Franko, PhD, the authors point to one common finding among their patients: the feeling of “I’m not good enough.” They note that eating-disordered kids come from a wide variety of backgrounds: some report idyllic and happy childhoods, some have a history of trauma or abuse. “The paths that lead to ‘I’m not good enough,’ differ from one person to another,” they write.

n Johanna Marie McShane, PhD and Tony Paulson, PhD's book Why She Feels Fat: Understanding Your Loved One's Eating Disorders and How You Can Help, the authors take readers inside the mind of an eating-disordered person and attempt to explain the anorexia sufferer's baffling conviction--no matter how skeletal her body may appear--that she is fat.

Eating disorders, write McShane and Paulson, can be many things: A way to feel secure, a way to make life feel predictable, a means of communicating emotions, a way to simulate the calming sense of "being in control" for the person who feels his life is completely out of control. Eating disorders, in other words, are a solution to that feeling of not being "good enough." Eating disorders become a cherished coping mechanism.

I recently came across another explanation/interpretation of the eating-disordered mindset, in Eckhart Tolle's A New Earth: Awakening to Your Life's Purpose. "In the West, it is the physical appearance of the body that contributes greatly to the sense of who you think you are: its strength or weakness, its perceived beauty or ugliness relative to others...Many feel a diminished sense of self-worth because they perceive their body as ugly or imperfect."

Leaving aside the fact that there are plenty of people in the eastern hemisphere who feel inadquate because of their outward appearance, Tolle captures a common feeling that describes nearly everyone as well as the severly eating disordered. He attributes this faulty perception to being overly "mind-identified," a condition in which one's ego is in the driver's seat and fails to see that the real essense of a person does not lie in a body "destined to grow old, wither and die," but in "the formless dimension, the light of consciousness" that "can shine more easily through the fading form."

He's not completely fixated on conscious awareness and non-being, though, allowing that "If [one's body] is strong, beautiful, or vigorous, you can enjoy and appreciate those attributes--while they last. You can also improve the body's condition through right nutrition and exercise." Tolle adds, "If you don't equate the body with who you are, when beauty fades, vigor diminishes, or the body becomes incapaciated, this will not affect your sense of worth or identity in any way."

Tolle's remedy for egoistic body-identification is to focus on "the feeling of aliveness inside" the body rather than by obsessing about outward flaws. Instead of getting lost amid incessant negative mind chatter he advises focusing on a calming "inner body awareness." In its attempt to correct basic errors of perception, his approach shares some aspects of cognitive behavioral therapy, in which a therapist helps restructure the patient's erroneous assumptions about herself.

Drs. Herzog and Franko advise counseling a perfectionistic child to strive for "excellence, not perfection." They note, "Excellence is achievable; perfection isn't."

In our book, Marcia and I note that low self-esteem is the most potent risk factor for both disordered eating and a full-blown eating disorder. We advise trying to foster a sense of autonomy in your child, the feeling that she has control over important aspects of her life. Give her opportunities to succeed within in the family, such as playing a role in making important family decisions, or helping with at-home projets. Praise skill, achievement, mastery and personality traits such as kindness, generosity and fairness, not appearance. Teach your child to understand to identify his feelings, and understand that even those that are unpleasant or painful are legitimate. And instead of using food to soothe, calm or reward a child, offer him a hug instead of a cookie.

We'd love to hear your suggestions for teaching better coping mechanisms and raising your child's self esteem.

Complex Anorexia: When to Move to a Higher Level of Care

2013-01-15T08:56:35-08:00

One of the most challenging aspects of treating complex cases of anorexia is cutting through the day-by-day storm and stress of treatment, to clearly see the arc of the disorder and make the right decision about when it's time to move to a higher level of care.

How do you assess a chaotic picture that includes incremental improvements followed by backsliding, pleading, anger, cajoling, broken promises, emotional outbursts and parental pleas that accompany the refeeding process?

As promised in my last post, here I'll summarize a set of benchmarks created by Drs. Michael Strober and Craig Johnson, in a recent paper published in The International Journal of Eating Disorders. The two doctors followed their paper up with a workshop at The Renfrew Foundation Conference for Professionals on the complexities of anorexia and how to treat it.

In their paper the authors explain their benchmarks are a “frame of reference” derived from scientifically supported observations and “an immense amount of clinical experience.” Here are their guidelines, directly quoted:

Consider inpatient care as a first intervention when there is:

1. A steeply declining trajectory in body weight, especially when weight is already below 75% of expected weight for age and height.

2. Irrefutable insistence by patient that further weight loss is needed, or justifiable, because of an over- weight or ‘‘obese’’ appearance.

3. History of an extreme degree of regimentation or compulsiveness in behavioral routines from early in life; extreme fear of maturational challenge; a history of trauma, extreme hyperactivity (multiple hours of unrestrained activity), or comorbidity with major depression or obsessive compulsive disorder when their symptom intensity results in impairment on their own, or is compromising weight restoration.

When to End Outpatient Care and Step Up to Hospital Care:

[These benchmarks apply to the scenario involving an underweight child, adolescent, or a young adult, regardless of her or his previous treatment history.]

1. If weight declines steadily over the first 3 weeks of treatment (or following consultation if no treatment was initiated). In our experience, this trajectory becomes difficult to interrupt thereafter.

2. Weight is initially stable, but there is a negligible average weight gain (or a waxing and waning pattern of increases and decreases) by the end of month two of treatment (or following an initial consultation). In our experience, a steady, uninterrupted increase in weight back to normal body mass becomes increasingly less likely after this point.

3. There is initial weight gain, but the slope of the increase levels off prior to the patient achieving full weight restoration, and this flattened pattern remains unaltered for at least 6 continuous weeks.

[The authors note that if there is a change of therapist, these benchmark algorithms start over.]

These benchmarks apply to older adults at low body weight who have been ill for at least five years:

1. Weight is declining steadily in the first three weeks after commencing treatment.

2. Weight is initially stable, but the patient is unable to initiate, and then sustain, a steady increase in weight by the end of month three of treatment; in our experience, uninterrupted weigh gain after this point is increasingly unlikely with such a patient.

3. Weight increases initially, but the slope of this increase then levels off and remains so for 3 continuous months.

The authors preface their guidelines by repeating their warnings that these benchmarks have to be applied within the context of seeing anorexia as a highly complex disease. In summary, their caveats:

Though a patient may exhibits “noteworthy” improvements, the continuation of even mild symptoms should not be taken lightly.
Lack of early weight gain in outpatient therapy may indicate a limit on what can be achieved over time.
Single interventions will not suffice when a disease as complex as anorexia is at issue, and psychological care should be present at all times in conjunction with other treatments.
Beware of therapist inexperience, which can result in either an overly lax approach when more oversight is needed, or excessively rigid control when more time is needed to let the treatment course evolve.
A patient’s “avowed enthusiasm for eating,” the doctors ask us not to forget, “is often the last refuge” in an attempt to avoid a more intense level of treatment. “The appearance of change is not necessarily meaningful change,” and failure to recognize the difference can have serious consequences.
The longer the illness goes on, so will it’s damaging effects on the physical health and the independence of the patient.

I look forward to hearing your reactions and feedback to these guidelines.

Are Current Treatment Approaches to Eating Disorders too Narrow?

2013-01-07T07:30:00-08:00

This blog post started as a short report on a workshop held at the recent Renfrew Center Foundation Conference for Professionals in Philadelphia. It was titled “Understanding the Complexities of Anorexia Nervosa and Implications for Therapeutic Management,” but many attendees knew the back story: that the workshop was prompted by a controversial paper written by its two leaders, Drs. Michael Strober and Craig Johnson.

The polarizing paper, published in the March 2012 issue of The International Journal of Eating Disorders, bears the unwieldy title “The Need for Complex Ideas in Anorexia Nervosa: Why Biology, Environment, and Psyche All Matter, Why Therapists Make Mistakes, and Why Clinical Benchmarks Are Needed for Managing Weight Correction.”

At the November Renfrew Center Foundation workshop, Dr. Strober referred to the paper’s fallout of “handwringing, angst, and statements on the (American Academy of Eating Disorders) list serve that were frank and critical.”

The paper, Strober went on to say, was prompted by his and Dr. Johnson’s increasing dismay over the “increasing reduction, narrowness and singularity of treatment paradigms.” qualities which he called “simply a marriage that does not work” when applied to treating an illness as complex and challenging as anorexia nervosa.

As your faithful blogger, I realized that in order for the Renfrew workshop contents to make sense, it would be helpful to give you some background by summarizing the academic paper the duo wrote.

So here goes. Bear with my explanation, for there really is a practical application to all of this, although I won’t get to it until my next post.

The paper took on the two prevailing treatment paradigms for the treatment of anorexia today. The first is Family Based Treatment (FBT, also known as the Maudsley Approach), which is founded on the belief that far from being the cause of their child’s disorder, parents must play a key role in their child’s recovery by refeeding their child in order to restore her or his weight.

At the same time that this widely heralded treatment has been gaining adherents in the U.S. (it originated in England over 30 years ago), many in the profession have increasingly advocated the second (and not mutually exclusive by any means) paradigm that Drs. Strober and Johnson took on, based on the importance of genes and biology in the genesis of an eating disorder. According to the proponents of this paradigm, there is irrefutable clinical evidence that eating disorders are one of many biologically based mental illnesses (BBMI for short), and they should be treated as such. You can read the American Academy of Eating Disorders position paper on the issue here.

Both in their paper and at the workshop, Drs. Strober and Johnson were at pains to acknowledge the value and importance of both treatment paradigms, even as they lamented the overly doctrinaire attitude that they say both camps have taken on.

In their paper, they noted “three worrisome trends: (1) that many therapists apparently see no place for the sort of clinical wisdom that can never be manualized [FBT is touted for its evidence-based manuals for both professional clinicians and parents on how to help reefed their anorexic adolescent or teen, and further manuals dealing with bulimia and binge-eating disorders]; (2) that the emphasis on empirically validated interventions is drawing attention away from more broad-based training experiences; and (3) that therapists who will one day encounter very ill patients are not being prepared adequately for taking on the many complex predicaments they will face.”

The paper and workshop also make a plea for appreciating the complexity of anorexia. Strober and Johnson write, “after biology, the rearing environment—the larger social context too” must be addressed, aspects of eating disorders treatment that have been devalued of late. They advocate the “common sense notion” that therapies shouldn’t overlook the parts of life that “potentially maintain or accentuate vulnerability: the family, school, or interpersonal environment.”

The family, in fact is a primary concern of the authors, who write, “The notion of stress engendered vulnerability is not at odds with treatment models that see families as critical partners in care; it argues that broad attention must be given to sources of intrafamilial strain and the need for other forms of therapeutic dialogue to reduce it.”

Although this topic may seem overly theoretical, there is actually a practical aspect to both the doctors’ paper and their Renfrew Center Foundation workshop that I will go into in my next blog post, namely their recommendations for benchmarks to help eating disorders professionals answer a question that plagues many parents and patients: “How do we know when a course of outpatient treatment in anorexia has reached the limit of benefit and we need to move to a higher level of care?”

Stay tuned for a summary of Drs. Johnson and Strober’s recommendations.