Author: ncfed

Palliative Care for Treatment Resistant Anorexia (TRA): Activism versus Advocacy

Posted on by ncfed

The Times  of October 28th 2024 featured the question of palliative care for anorexia. Predictably this has generated a strong response from eating disorder activists, patients and carers who deem this a bad thing.  Let me say that I write this as an eating disorder Advocate, not an Activist. Activism has value but is often based on personal experience;  it represents a kind of passion akin at times to a mania generating strong views that can be biased, emotionally laden  and preclude listening to other points of view that need airing.  Can palliative care have its place among the care options for treatment resistant anorexia?

Palliative care is NOT ‘leave them alone to die’. Palliative care is a specialized medical care that aims to improve the quality of life for people with serious illnesses, including mental illnesses and to help relieve their suffering. It can be provided in many settings, including hospitals, nursing homes, and at home. Anorexia Nervosa is very special by invoking a compulsion to avoid treatment or only accept treatment that is destined to fail. (Quoting Janet Treasure). In early stages, people may deny that they are ill, there are aspects of the illness that give them joy or protect them from suffering even unto death, and this contributes to resistance to “best efforts” to help them.  Low weight and malnutrition make the anorexic brain resistant to psychotherapy.  Even where a person “wants” to recover, the means for that recovery are infinitely worse than staying as they are.  Perhaps they want to recover but stay thin, in which case recovery is never achieved. Death may be preferable to “being fat”.

Anorexia also has profound effects on treatment providers who may fail a very sensitive patient by saying the wrong thing, by not knowing what to do next – because NO ONE has a treatment strategy that is guaranteed to work – and by eroding into the same helplessness that is faced by their patients.  We live by cliches such as “we must not give up on them” and that “we must hold hope for them” – which we absolutely do,  and this effort can feel overwhelming and a very lonely task. 

I argued in an earlier blog against constant trying to treat people with treatment resistant anorexia, instead with each patient’s history in mind, perhaps we should just aim to keep these souls alive by any means possible including periods of enforced refeeding in emergencies, compassionately and for as brief a time as possible since anorexia is a form of psychosis so it could be argued that we are not abusing the patient, rather, we are facing down the illness that keeps them captive. This could be our main outcome until they find their own way (or not) to reach a turning point in their illness. Some do, and it is not always because they found the right therapist. It was just the right moment in time.

Where a person with AN has endured rounds of refeeding, and heinously costly inpatient stays, but little changes, perhaps we need to consider palliative care. This option focuses on improving quality of life for patients when traditional treatment options have failed. Here are several points in favour of this approach:

  1. Holistic Approach: Palliative care addresses the physical, emotional, social, and spiritual needs of patients. This comprehensive care model can help individuals with anorexia find relief from distressing symptoms that may not be effectively managed by standard treatments.
  2. Focus on Comfort: For patients who have not responded to traditional therapies, palliative care emphasizes comfort rather than curative treatment. This can include pain management and support for physical symptoms, promoting a sense of well-being even where the patient is desperately ill.
  3. Supportive Counselling:  Palliative care includes compassion-based conversations, including about death but never as a threat of continuing to starve. Such conversations include how to live one’s best life despite grave disability, and the meaning of life. Such mentoring provides a safe space to address feelings, fears, and motivations.
  4. Family Involvement: Palliative care often includes family members in the care process, ensuring that they receive support and education. This involvement can enhance the overall care and understanding of the patient’s condition.
  5. Quality of Life: By prioritizing quality of life, palliative care aims to enhance the patient’s ability to engage in meaningful activities, find enjoyment in daily life, and improve overall emotional health.
  6. Interdisciplinary Team: Palliative care typically involves a team of health professionals, including doctors, nurses, dietitians, and social workers, who collaboratively develop personalized care plans tailored to the patient’s unique needs.
  7. Reduction of Shame and Stigma: Providing care that acknowledges the chronic nature of some eating disorders can help reduce stigma. This approach fosters an environment where patients feel accepted and understood.
  8.  Externalising the Argument: Offering palliative care could in some cases galvanise recovery efforts. By returning the “wish to change” to the patient, the therapist is  no longer seen to have responsibility for battling the anorexia. This is something that the patient will need to do on their own, and some do.

On November 26th 2024 The Royal Society of Medicine will deliver a daylong seminar on palliative care for mental health problems including eating distress. https://www.rsm.ac.uk/events/palliative-care/2024-25/plt01/

Please attend before you take sides, because palliative care can play a crucial role in the management of treatment resistant anorexia by addressing symptoms, improving quality of life, and offering compassionate support to both patients and their families. It is particularly valuable when conventional treatment options have been exhausted or when patients choose not to submit themselves to further aggressive treatments.

ALL-IN FOR ANOREXIA, USEFUL? OR RISKY?

Posted on by ncfed

The “All In” approach for anorexia treatment, which focuses on unrestricted eating, rapid weight restoration, and the removal of all food-related rules, can be beneficial but also presents some challenges. Here are some pros and cons:

Pros:

                1.            Rapid Weight Restoration: This approach can help individuals quickly regain weight, which is critical for restoring physical health and cognitive function.

                2.            Simplicity: It eliminates the need for complicated meal planning or calorie counting, reducing the focus on food-related anxiety.

                3.            Psychological Relief: By allowing all foods without restriction, it can help break the cycle of food fear and encourage a more positive relationship with eating.

                4.            Reduction in Long-Term Obsession: The freedom to eat anything can prevent long-term fixations on “forbidden” foods, supporting long-term recovery.

Cons:

                1.            Overwhelm: For some, the lack of structure and sudden change can be overwhelming and anxiety-inducing, making it harder to comply.

                2.            Medical Risks: Rapid weight gain can come with medical complications, such as refeeding syndrome, especially if not monitored by a healthcare professional.

                3.            Psychological Resistance: Many individuals with anorexia struggle with letting go of control, and an “All In” approach may lead to resistance or rebellion.

                4.            Not Individualized: This approach might not be suitable for everyone, especially those who benefit from a more gradual or structured reintroduction to food.

It works well for some, particularly when done under proper supervision, but it requires careful consideration of each patient’s readiness and health status. There is also no evidence base regarding its effectiveness. I  haven’t encountered anyone who has used the “All In” approach, and I don’t know how it fits within the broader spectrum of treatment methods for anorexia. Its more radical nature can be a good fit for some individuals, but it’s less commonly adopted in comparison to approaches that use more gradual, structured reintroduction to eating, such as Cognitive Behavioural Therapy (CBT) or Family-Based Treatment (FBT).

Bear in mind that many quirky or trendy treatments can be risky without sufficient research backing them up. Sticking to evidence-based approaches ensures that we are providing safe, proven methods to help patients recover.

In the case of anorexia, treatments like CBT, FBT, or even newer advancements like Maudsley-based therapies have strong research support. Our emphasis on what’s been thoroughly tested aligns well with best practices in the field. It’s important to strike a balance between innovation and caution, especially when health is on the line.

I do not know how I would respond to a parent who demands this kind of treatment. As far as my experience goes, I have not yet met a person with anorexia who agrees to eat this way. If they did, they would need to be closely monitored by a medical team due to the potential risks.

I would find it useful to find out what other experts think or to get info from sufferers. So far I don’t know any expert who is for it.

Is it time to call time on anorexia memoirs

Posted on by ncfed

A personal and possibly controversial plea

There is a kind of book that some people unkindly call “misery-memoirs”; usually some form of illness or adversity in childhood. Where anorexia is concerned, a lot of books have been written by former or current sufferers. They were once thought useful to inform clinicians what the sufferer experience of anorexia is like.

We have been asked to read a lot of these memoirs, some unpublished, some self-published and some taken on by a publisher who invites us to endorse them. They are much the same. They take the form, as follows;

  • Person is unhappy and in some cases feels wrong in their body.
  • Person loses weight and becomes unable to start eating normally
  • Person begins acting psychotically. One describes sneaking down to the laundry to drink water that had accumulated in a tumble dryer so that their weight will appear higher; one won’t smell food in case he absorbs calories through his nose. One falls off their bike and fractures their hip but escapes from the emergency room to complete their ride in case they gain an ounce of fat. One decides to walk the Camino Trail at a BMI that might kill her, to prove to people that she is fine at the weight she is. One man has written a personal account riddled with obscenities (wash your mouth out, hun) Most run silly distances on empty. To top it off, all speak of a bully, a voice that orders them about and which cannot be challenged.  

There is no doubt that people with anorexia crave to write books about themselves. With some exceptions, few of these books give time to the recovery process; rather they dig deep into descriptions of suffering. I have asked why this is so but have had no answer.  When we are offered yet another anorexi-ography, we read it in case there is something useful, but are mostly disappointed and, also to some extent troubled and  traumatised by the familiar madness revealed in the pages.

This sounds as if I am unsympathetic; I’m not. There is evidence that accounts of anorexia traumatise health professionals.  Anorexia is a terrible psychosis where the therapist is destined to engage in a dance with someone whose illness thwarts change and where I am always at risk of becoming the enemy with one word or gesture out of place.  

There are some superb personal accounts that are valuable for one reason or another.  With one recent exception (Hadley Freeman: Good Girls) there is no need to have any more memoirs to add to experience or add anything useful to an existing bibliography written by people who have fought their way to recovery with focus on that. I can tell always when people claim to be better but they are not. They have just morphed into marathon runners or clean eaters. Reading a great book about recovery (see The Reading Cure by Laura Freeman or Life Without Ed by Jenni Schaefer) I am thus edged from trauma into hope.

Many people with anorexia will recover or partly so with or without psychotherapy. When they reach the spot where the mania softens, this is the time when they start thinking about writing a book about themselves. Is this just another manifestation of the narcissistic core of anorexia?  I would say – no more please – unless you want a memoir for your eyes only. Perhaps start living the life that anorexia stole from you and stop thinking about the past.  We have enough great books (see our website book list) and do not need ANY more.

As someone who once had anorexia (and now do not) I never had the need to write about myself. Perhaps that’s the healthiest place to be.

WHATS WRONG WITH “ATYPICAL ANOREXIA”?

Posted on by ncfed



I have heard it proposed that the description “Atypical Anorexia” should be ditched.

Eating disorder classifications have changed over the years. We have had eating disorders classified in many ways, as anorexia, bulimia, ednos, fednec, osfed, orthorexia, and so on. Some psychiatrists even tried to have “obesity” included in eating disorder classification. We do NOT call each variant a “diagnosis” and we should not confuse a “classification” with a diagnosis.

The classifications were invented for a number of reasons. Most importantly they were

A             to legitimise treatment and to make it available to people who beforehand viewed their behaviour as mad or bad.

B             to identify treatment pathways that are appropriate for the behaviour in the room. One would not treat a 14-year-old restricting person the same way as a middle-aged overweight person whose eating was objectively out of control. Well-meaning professionals have devoted their lives (think Janet Treasure or Christopher Fairburn) to developing treatments for different client presentations.

The criteria that led to the classifications were based on frequency of observed behaviour and time.  We have also needed to add thinking typical for each classification. For example, with anorexia nervosa there is a relentless pursuit of low weight that is not experienced by people who lose control of food and who are not underweight.

To qualify for having an “eating disorder” you have to be doing what you are doing fairly consistently and to be doing it often enough that it makes a difference to your life. If a person overeats and then induces vomiting to avoid weight gain once every 6 months, it is hard to know what is wrong,  if at all.

The problem therefore with classifications is that they have never been clear-cut and people do not fit neatly into just one classification as they exist right now. To have anorexia, at the moment, one criterion is to be underweight at a specific level. Anorexia is also a mindset, that is well understood by  people who are trained clinicians. So where do we “fit” someone with an anorexic mindset but who is not underweight or just marginally so?

Where do we fit people who compensate for overeating by purging but not very often?  And where do we fit people who purge without having overeaten beforehand?

The eating disorder classifications as things stand – allow for this variance by saying that there is behaviour that fits the current criteria; and there is behaviour and thinking that almost fits but doesn’t tick all the boxes, one being weight.

Let’s make one thing absolutely clear. We need to sort a client into one or more categories for our own protection and for ethical practice.  I mean, a client can have bulimia and ALSO present with orthorexia or night eating syndrome. When we have sorted this in our own mind we can determine an evidence-based adaptable treatment plan. I had plenty of clients over the past 40 years who behave and think like people with anorexia nervosa. But they are not underweight. The person who first comes to mind was anorexic without doubt but she had a BMI of 30. The reasons for this are complex. Am I going to call them OSFED or FEDNEC cases?  Is that better than ATYPICAL ANOREXIA?

I really don’t care.  I have enough experience to think of my client as I choose. The issue is,  do we NEED to tell our client about what label we have assigned to them?  Whatever “diagnosis” we give them is arguably dehumanising.  Does it really make a difference to think that my client has OSFED or a condition that is similar to anorexia, but not quite?

The OSFED and FEDNEC categories are much too broad for my liking and mean nothing for a treatment plan. If you are going to surrender the labels “atypical anorexia / bulimia,” then first decide what you will replace them with, and whether it makes a difference.

AT NCFED in our interactions with clients, we often (not always) avoid labels. Because they don’t help with engagement or therapy outcomes. We know how to decide if they have an unhelpful, harmful relationship with food and we invite the client to create their own identifier for their experience of eating and body weight. But as clinicians, we have some tick-boxes to rely upon to determine a category, for ethical reasons.

The category “atypical anorexia” has meaning, and specific symptoms. If you can come up with something more useful and why, please let me know. I’m listening.

WHY DO I NEVER FEEL FULL?

Posted on by ncfed

I never feel full.

This was the complaint of one delegate on our obesity training. It led me to think about fullness, satisfaction, having enough (satiation) or not caring to eat another bite.

The sensation of fullness is not quite the same as satisfaction. Satiation is a problem for many people living with overweight. Satiation studies have identified people living with obesity who don’t feel as if they ate enough, and they get hungry faster too. Satiation may be identified by slowing up as an eating event proceeds. Some people just don’t seem to slow up. What can be going on?

We note that from birth, some children have an enhanced susceptibility to eating more, when food is present and according to their parent’s opinion, they are always asking for more food.  According to the “Food Responsiveness Theory,” these children are at greater risk of weight gain in childhood and risk being overweight as adults. We suspect that maternal diet before conception and during pregnancy may have something to do with this.

Fullness, satisfaction and satiation result from an interplay between physical and psychological factors. The physical influences are a complex interaction between our genetic footprint,  stomach and gut, appetitive neurochemistry and a  range of neural structures in the brain, the hypothalamus and the opioid or reward centre in the brain.

A satiation response tends to be good in early life, it is barely possible to overfeed a breast-fed baby, they just turn away when they have had enough. Toddlers spit food out when sated unless we can entice them to eat a little more, usually by distracting them. From the age of 7, our innate ability to eat what we “need” becomes impaired, especially if we are in an environment where tasty food is on tap. Our Palaeolithic origins have designed us to eat a little more than we “need” because of the possibility of food shortages. The satiation response is always weaker than the hunger drive.

An eating disorder therapist needs to understand the biology of satiation after eating, that arises from sensory experiences in the Enteric Nervous System (mouth, oesophagus, stomach, liver, gut etc) together with the effect of the chemicals of digestion entering the body and the brain.  During the process of feeding and digestion, several things can go wrong and I mention only a few of these.

The food itself

The food we eat can affect our ability to feel full. Books  have been written about the poor satiation effects of foods containing UPF; so people can eat a lot of food and still feel hungry. I don’t want to repeat the evidence here, but it has become very difficult in our food environment to get food that is UPF-free. Even our cows and farmed fish are fed UPF which is passed to us when we eat their flesh, unless we are buying grass fed organic beef or wild fish.

Note that children eat less and are better nourished when they are given food that looks close to its source ( a fish rather than a fish finger) .

Malnourished

Many people who say that they never feel full have taken in a lot of calories but they are malnourished. Calories alone don’t create fullness, it is the nutrients that make a difference. The foods that contribute to satiation in the short term (fullness) and in the long-term (lower hunger levels)  include good quality protein vitamins, and minerals from having a rainbow diet with plenty of fruit, veggies and Omega 3 fats. And while I am on the subject of fullness and diet, let’s not forget the importance of …

Fibre

It is hard to feel full on a diet lacking in fibre.  You may feel temporarily stuffed on a plate of cornflakes, but compare the sensation after eating a bowl full of porridge oats with a handful of seeds thrown in.  No contest.

Omega 3 Fats

Deficiencies in any nutrient can interfere with satiation but there is a particular place of importance for Omega 3 fats, ideally as fish oil. Omega 3 fats prime neurons throughout the brain to respond to the sensations and chemicals that inform that brain that sufficient nutrients are present.  When the ratio of O6 to O3 fats in our diet is too high in favour of O6, there will be high levels of inflammation affecting the weight control and satiation centres in the hypothalamus. I wonder how many of our clients / eating disorder specialists are aware of this.

The mouth

Mouth-feel of food can affect how satiating it is. Adding a spoon-full of olive oil to a salad makes it feel more satisfying and therefore more “filling”. Rats who get mouthfuls of food that doesn’t reach the stomach (surgical diversion) stop eating after a while, but they start wanting food again sooner.

The stomach

Fullness of the stomach contributes partially to the sensation of “enough”. We have stretch receptors, mostly in the lower pouch of the stomach (fundus) that send fullness signals through the vagal nerve to the brain, switching off the neurochemicals that make us hungry.

Years of overeating or binge eating can downregulate the stretch receptors so that the fullness signals become weak .

People with a gastric band continue to feel hungry because the small pouch receiving food is at the top of the stomach. The fundus where the stretch receptors are located just don’t get the signals that can stop us from feeling contentedly full.

The gut

The gut contains sensory receptors. When stimulated by the passage of food, they produce peptides such as Pyy3-36  that, when activated by the passage of food, suppress appetite neurochemicals in the brain.

Speed of eating and distraction

We have known for decades that eating fast and mindlessly increases the amount of food we want to eat before we register that we have had enough. Slowing down gives our brain and body a chance to register the nutrient delivery of food. Eating fast also weakens the stretch receptors in the stomach and if that isn’t enough, fast eating impairs the production of a “fullness hormone” produced in the small intestine, namely CCK.  . Want to feel full? Slow your eating doooooown.

Distraction also plays a part in stopping people from registering their satiation.  The Health psychologist Jane Wardle showed us that people who eat with food on their knees while watching TV managed to polish off 3 times as much snack food in the afternoon following their meal, compared to people who ate at a table just talking to each other.

The Hypothalamus

This is an organ deep in the brain that acts like a thermostat for our appetite and body weight. I will not try to do justice in this short article to the neural concomitants of satiation. AS far as appetite and weight control is concerned, the hypothalamus responds to leptin signals that come from fat cells. If leptin levels are high, the hypothalamus adjusts our nervous system to burn more energy and switches off our appetite.

Sadly, years of eating “the wrong kind of food” or overeating can deafen the hypothalamus to leptin signals. The culprit here is insulin – a hormone that we unwittingly overproduce when eating an unhealthful diet. Hypothalamic deafness to leptin means that no matter how much fat we carry, we continue to be hungry. Many people in large bodies we see eating large amounts of food have lost their hypothalamic “off-switch.”

A history of calorie reduced dieting

Dieting leads us to attend to what we “should” eat rather than attend to the natural signals of hunger and satiation. We also tend to eat less than we need to lose “fat”.  When we stop attending to our natural appetite, that is mistrusted, we stop knowing how and when we are full. Our eating will become permanently disinhibited (eating in for all sorts of reasons) and dysregulated (eating past the point of fullness).

The Reward (Opioid) centres of the brain

Eating satiation is also affected by how rewarding the eating experience is. Pleasure and satisfaction from an eating event contributes to fullness and not wanting to eat more. Years of eating high-fat-sugary foods leads to a dulling of the dopamine receptors that make eating a nice-good-enough-for-now experience. Binge eaters are often chasing the dopamine high that they find works less well for them, and they would find giving up binge eating difficult since normal eating doesn’t satisfy them anymore. If your opioid system isn’t doing its job, you may feel full or even nauseous, but you will keep needing to carry on eating.

Psychological Factors

The Eyes

We evaluate with our eyes in many cases how satisfying a meal or snack is likely to be. People who are blindfolded eat in some cases 50% less of a meal than if their eyes had been open.  In many cases we need less than we think will sate our appetite and delay future hunger. I am not recommending that we all eat on smaller plates, but we need to find a way to stop our eyes from telling us when its OK to stop eating.

Interoception

Interoception is the psychological ability to sense what is going on in the body. Many people with eating disorders and obesity who claim that they are never full, lack interoception and they have no idea when they are full. (and in the case of anorexia they may not know that they are hungry). Interoception is both intrinsic and it is a skill that is lost because of many things, including trauma. In therapy for obesity (and eating disorders) it is important to teach interoception. It is a simple but important skill, leading to better awareness of appetite, fullness and emotions.

Old habits die hard

Eating habits formed during the lifespan are affected by a huge range of influences regarding the amount or type of food we choose to eat. One example might be getting a needed emotional reward for clearing your plate when you are a child. In this way, the child becomes attuned to what they want to get rather than what their body says they need. Obesity therapists need to look carefully at the habits a person has formed. Might the explanation of why their client never feels full lie here?

Stress

The effects of psychological stress on the ability to “feel full” are variable. Stress may lead to fast or distracted eating or give some people tummy upsets and IBS. Obesity therapy must address stress as part of a treatment package that is designed to foster health behaviour change.

The eating Gestalt
Satisfaction and satiation after with any eating event depends on the eating event itself. Small things like sitting down at a table in a nice environment with nice tableware can contribute to psychological satisfaction as well as physiological satiation. People who eat on the run, in a car or in a haphazard way tend not to feel full, or the satisfaction is transient.

Conclusion

If you have a client who says that they never feel full, many things are going on. You may have to attend to all the things that I have listed as possible problems.

Perhaps begin with interoceptive awareness training and nutritional rehab. Ensure that the diet is as nutrient dense as possible with plenty of fibre and Omega 3 in the form of oily fish.  Make sure that the client begins eating slowly and without distractions. Above all, ensure that for a while there is no alcohol because booze muddles the appetite pathways.

There is no shortcut to restoring the ability to feel full on moderate amounts of food. Obesity therapy is a long slog, and the client deserves to give themselves the time to change.

Fat Activism, with respect?

Posted on by ncfed

The Founder of NCFED (me) and Dr Adrian Brown a clinicial at Imperial College Raised a complaint against a Fat Activist for issuing racist comments about each of us and disseminating incorrect information about our treatment of binge eaters and people in larger bodies.. The GMC have investigated our complaint and have registered a warning against this person’s record.

The judgement of the GMC included these comments:
The Committee finds that “”Doctors” conduct constitutes a clear and specific breach of the
professional standards, most notably paragraph 65* of Good medical practice (2013) which says
that, as a doctor, ‘you must make sure that your conduct justifies your patients’ trust in you and
the public’s trust in the profession.

  1. The Committee also finds that although Doctor’s conduct is serious, it falls just short of that
    which would be considered serious enough to pose a risk to public protection. The Committee
    considers that, if there were to be a repetition, the threshold for restrictive action on “Doctors”
    registration would likely be met.
  2. In reaching its decision on seriousness the Committee considered the Doctors lack of insight and acceptance that his comments were inappropriate. Dr X has expressed no regret or remorse or offered any sort of apology. He has taken no steps to address the behaviour that led to the complaints. Consequently, the Committee must conclude that the risk of repetition is high.
  3. The Committee regards that action, in the form of a warning, is appropriate in the interests of
    promoting and maintaining proper professional standards and conduct for members of the
    profession and because of the potential impact on public confidence in the profession. It is the
    Committee’s view that Dr X’s comments are offensive. It was particularly concerned about
    the impact the comments may have on the confidence of a cisgender, white, heterosexual male
    after reading about the Doctor’s dislike of his ’species as a general rule’ and him having to ‘work
    real damn hard to get into my good books’. The Committee has concluded that an individual
    could well assume that they may not receive fair treatment from said Doctor.

Your colleague and Founder (me) has also been accused on the Doctors Social media post along with All-Bodies Recovery of being white, cis-gender, fat-phobic and thin-privilege- although this doctor does not know what I weigh nor the size of someone who was my husband. It was disappointing to have discovered that one of our Network “liked” the half hour long, very offensive video in which these comments were made.

Despite the said Doctor’s stated intention on social media to stop us doing what we are doing, we go from strength to strength. If we always do what we believe is right and we have the interest of our clients at the heart of our actions, we will thrive.

Is Anorexia just Body Dysmorphic Disorder?

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On having this interpretation of anorexia offered to me, my first reaction was of course not! Although in the 1980s a famous eating disorder clinician named John Stonehill proposed that all the eating disorders be renamed “Body Image Disorders”. The concept never caught on.,

A key feature of body dysmorphic disorder is that people have fixated beliefs of bizarre content regarding their body or aspects of their body, such as their nose or facial appearance. This is usually accompanied by compulsive behaviour to deal with their beliefs (such as avoiding mirrors or hiding). Insight into the deluded thinking is lost and there is no resistance to compulsive urges to engage in compensatory actions.  The rituals that accompany BDD can be disabling, and what interested psychiatrists was that no sufferers had other forms of thought disorder and so they could not be viewed as psychotic.

A person fixated about the size of their nose would thus perceive other aspects of their life fairly normally. Because of the rituals associated with fixated thinking,  for a long while BDD was regarded as a form of obsessive-compulsive disorder.

Anorexia sufferers may believe with absolute certainty that they are fat even when they are emaciated. They also have extreme shifts in body perceptions after eating food that they deem forbidden or fattening. Hence these foods are avoided in extremis. Eating disorder clinicians call this “thought-action-fusion”, a disorder of thinking, not of the body itself.  Anorexic beliefs, despite their fixated nature, are thus considered to be overvalued  ideas that are not “alien” beyond common understanding,  unlike other forms of BDD.   Their content (food is dangerous, I’m fat) is experienced by many women and men. Its just that this disturbance is at the extreme end of a spectrum and matters a great deal.  Many people share beliefs about being “too fat” but the impact of these ideas on their wellbeing is minimal since their self-worth is vested in other things, like having a good relationship with their friends. In other words, their beliefs matter less.

It is true that people with BDD and with anorexia share a range of odd ideas about their appearance that range from the obsessional to the psychotically delusional. This has led clinicians to regard anorexia as a compartmentalised psychosis, necessitating enforced treatment such as nasogastric feeding in cases where a persons’ life is at risk.

My biggest concern about labelling anorexia as BDD is that it restricts our ability to look outside our mental box. A clinician with fixated opinions about the nature of any mental health  condition is blind about the other possibilities of what is going on.  Anorexia and other eating disorders share features with MANY other mental health conditions such as addiction, anxiety disorder, OCD, psychosis, to name but a few. Anorexia has also been conceptualised as a monomania, a developmental disorder, a cultural phenomenon or a rebellion against women’s place in a patriarchal society.  If you consider anorexia is BDD; and if BDD is a form of OCD; and if OCD is an anxiety disorder; and an anxiety disorder is a response to trauma,  then it follows that anorexia is a trauma condition.  Really?

Reductio ad absurdam.

What distinguishes anorexia from other forms of BDD is the Anorexic Voice. We all talk to ourselves but the Anorexic Voice is more persistent, intrusive and often concrete (i.e., real). Is the anorexia hence BDD with schizophrenia?  How one labels a complex condition like anorexia is of more than academic interest. A diagnosis of delusional disorder like this may lead to a lifetime of antipsychotic medication, which never cures anorexia.

And even when the scales fall from someone’s eyes, and they both know and feel that they are skin and bone, it still is not enough to get the anorexic person to start eating again. They are not suddenly recovered so what do we think is going on now?

It is unhelpful therefore to fit everyone with delusional beliefs about the body into the same diagnostic box, no matter how much we have vested our truth in it. We could, for example, call gender dysphoria a form of BDD, implying delusional beliefs about being in the wrong body, with extreme, compulsive  and aggressive actions taking place (hormone therapy, genital or breast amputation etc)  to help a person feel better. I am not sure it will go down well to place people questioning their gender to be forced into therapy for BDD.  (“You aren’t really a woman in a man’s body, you just have BDD”)


My final plea is to allow anorexia to sit in a place on its own, where it has aspects of BDD and OCD and psychosis and pretty much everything else. This is why it is so pervasive and difficult to treat. There is no single therapy or therapist up to the job of rescuing a person from their toxic relationship with food and with themselves. Unlike with other forms of BDD, recovery is concomitant with a rise in self-worth. I am going to fight the anorexia, because “I’m worth it”.

Deanne Jade 2024

Will Intuitive Eating Save you?

Posted on by ncfed

Intuitive Eating has had a good press. There are many Nutritionists and Therapists who describe themselves as Intuitive Eating informed.   It is the basis for the Health at Every size movement which is against weight-loss -dieting and this can only be a good thing because dieting is a bad thing, we all agree about that. Don’t we?

Many therapists who follow Attachment Theories of overeating are on this bandwagon, suggesting that, among other things, we allow and guide clients to reconnect to the natural wisdom of the body, helping people to narrow the gap between how they eat now,  and  what might be more healthy.

Some people who blog about  binge eating declare that anything they put in their mouth is OK and that could be helpful to deal with shame. Dividing food into good and bad isn’t helpful. But is that right?  It might serve people better to be nudged away from UPF even if it comes in a packet with trees on the cover, suggesting that this food is a healthy choice.

Babies – by and large- are intuitive eaters. Very young children feeding “ad libitum” (freely) , go for the strangest food combinations from one day to the next.  but over time their nutritional intake evens out and they seem, as if by magic, to eat the nutrients they need. 

But according to Bee Wilson, a food author, children lose that intuitive wisdom of eating by the age of 7 onwards. They are more likely to be “cued” to external signals like what food is available and whether it tastes nice.  It doesn’t help that our culture is full of attractive food that is designed to override our natural appetite, so it simply doesn’t make sense that in such a culture it is possible to eat intuitively any diet that could be regarded as “healthful”. There is simply too much “food noise” around us deafening our eating common sense.

Writing about deafness reminds me of other things that make it difficult to call upon the so-called natural wisdom of the body.  Most of us have some idea of what we should be eating (in theory) but it simply doesn’t happen, whether we are dieting or not. The neurological factors that affect our appetite, our body weight and ability to be appropriately satisfied after eating, depend  on many factors that are out of our control. Our eating drives are driven in part by our genes, our past and current history of eating and even our mother’s eating habits while we are in the womb.

Many people suffer “deafness” of a tiny area of the brain called the hypothalamus. This structure is like a thermostat  to monitor whether we have eaten enough or have enough fat on our bodies for the moment.  The hypothalamus listens for Leptin, a hormone produced by fat cells. Years of overeating makes the hypothalamus deaf to Leptin. We would be driven “intuitively “ to eat more than we need and we would be unable to stop eating even when we have had “enough”.

To rebalance the hypothalamus takes more than giving up dieting and certainly doesn’t mean eating whatever you fancy. I will write more about this later.  Treating hypothalamic obesity is complex.   

To add to the picture, we are designed to need pleasure from food as well as nutrients. The part of the brain involved in eating pleasure is called the Opioid centre. If our healthy diet doesn’t taste good, we have to  keep on eating. And people who have eaten badly for years have destroyed their capacity to get pleasure from normal amounts of food. Giving up dieting will not solve this problem and people will not be able to engage in intuitive eating without targeted help. So, one might ask, what kind of help does this imply?  Giving up dieting? Eating what you like without shame? Neither of these suggestions will work.

 As an idea or concept, “Intuitive eating” sounds nice and cosy but how can we get to this point?   Even the healthiest food that we ingest, such as salmon,  if farmed, may be contaminated by additives that are designed to cheat the neural systems controlling our appetite and our weight.  

Hard as it is for  people we are trying to nudge away from food rules, we have to give our clients an eating plan that at the very least regulates blood sugar and that also provides UPF-free nutritional density. But even with nutritional perfection, we cannot ignore the huge role played by psychology. Our eating choices are driven by more than physiology. Our desires are shaped by our childhood, our emotions, our self-esteem, our family systems and much more.

So the bottom line is,  nutritional therapists trying to help a client to “eat intuitively” are advised to work  alongside a specialist psychotherapist.  Binge eating bloggers may need to think twice about making it OK to eat anything we like. People need targeted help, not just strokes and platitudes. It takes more than the principles of Intuitive Eating to change a person’s relationship with food and weight from the inside out.

How to help people lose weight

Posted on by ncfed

A huge number of people come for guidance for weight change. Frustrated individuals go everywhere, to slimming clubs, bootcamps, to learn why they cannot succeed at weight loss, in the expectation that if they find the reasons for their “lack of willpower”, they will emerge sylphlike from the therapy room with their relationship with food corrected. These clients hope and are led to believe by unspecialised therapists, that they will find an explanation for their failure to lose weight in their childhood adversity, their poor attachment experiences or other traumas. Some clients even think that a hypnotist will convince their rampant unconscious to make a piece of chocolate taste like an onion.

Neither hypnosis nor counselling do the trick. Some therapists have built their reputations on attachment or trauma explanations for obesity, the thinking is that if you have had poor attachment experiences in childhood, you will be unable to use others or your own missing capacity for self- soothing and hence will develop an addictive relationship to substances like chocolate to get you through the slings and arrows  of life. It is a persuasive argument that has poor outcomes for changing someone’s weight. 

Weight-loss therapy rests on the premise that to lose weight (if this is the outcome) several things must come together. There must be Intention, this is about why a person wants to lose weight, and when. A person might want to embark on weight loss, but not yet- and maybe never, because one way of dealing with a problem is to ignore it.

To lose weight, intention has to move into Action, that is all the behaviours that are designed to make change possible. Please don’t assume from this that Action means “dieting” or “going to the gym”.  The intention-action gap is a bridge that is easily broken by temptation, other people or boredom among other things, or by having a very disordered relationship with food.

 It is the therapist’s job to help the client to bridge the intention-action gap and to make many different behaviours sustained for life. Whether you think of obesity as a disease or a moral failure or a curse, people who lose weight and maintain it must change some habits for life. This is the hardest thing of all.  

The weight-loss therapist needs to understand intention and the intention-action gap with compassion and academic wisdom – not with strong opinions and fixated ideas.

Let’s look at Intention to lose weight. Motivation to change is not the same as desperation, although many people who want weight-loss are desperate; they feel bad, moving hurts, maybe they are sick;   or diabetic, they don’t like looking in the mirror and they restrict many of the day-to-day pleasures that they think are allowed for slimmer folk.  I accept a client’s reasons for wanting weight loss, unconditionally and without judgment. I do not show myself enthusiastic about their wish to change their weight. I just  work quietly on what their Intention is about and leave decisions up to them.

The wish to lose weight comes from surface wants like “I want to be able to fit into normal clothes”  and also from deeper existential issues such as wanting to “be” different or to have a different kind of life. Intention is shaped by questions such as – what kind of person would I be if my weight were to change?  Would people who love me / approve of what I want to do, or would I be stepping outside of a family identity?   If I were to lose weight would I be hungry all the time? Will I have to sacrifice too many  nice things?  Would I be able to eat my favourite foods? Would I be the boring person at the party?  Would I be giving away my power to all the people who have said I should lose weight? What will be the costs of not losing weight; do I think I have it in me? Do I really want to follow someone else’s dumb rules. And last but not least, as an example, if I were to lose weight, would I get something really important out of it, like living to see my grandkids grow up. I don’t want to be driven by my hungry needy inner child.

So how do we think about Action? Does it mean going on a diet or going to the gym? Does it mean striving to reach a goal weight?  The answer is no.

Action, strangely enough, doesn’t target weight-loss as a treatment goal. Goal weights are heinous. Action therapy targets the vast range of behaviours and the attitudes that shape our behaviours, that make permanent weight-loss more likely.

Action therapy nudges clients toward some principles of weight change that are known to work, such as eating s…l…o. .w. .l. .y or,  getting rid of the biscuit tin. We are all wired to eat what is in front of our nose. Your kids don’t need biscuits; and I promise that they won’t need psychiatric help because you don’t have a fridge full of KitKats). Action might be something as small as not eating your main meals in front of the TV.  It might mean buying smaller Easter eggs, the day before Easter, not in the middle of January.

Action behaviours are affected by many things, each needing therapist attention or skills work. Old habits, stigma, people who do their best to sabotage you or, simply where you live. Certain skills are helpful, such as cooking, being able to read a food label; or saying no to the children who pester you for crisps in Tesco. Skills for managing cravings do not require years of psychotherapy. There are simple do-able tools that really work. Willpower is simply a neurological muscle we use to manage impulses and compulsions and we know how it can be strengthened.

The Intention-Action Bridge is weakened by unhelpful attitudes that keep a person stuck in their unhappy relationship with food. Limiting beliefs such as “I will die without my treats, or, I should never eat chocolate (or I will be a pathetic weak person) or, I was born to be big so there’s nothing can be done about it – all these mind-worms can be changed. Even an automatic belief like I shouldn’t have eaten that, What’s the point – I may as well carry on eating and I will start again next week.  We can erase this kind of thinking from a person’s mind.

Emotional eating

If we keep the intention-action gap as our central focus for obesity therapy, obviously there are many barriers that thwart Action. One such barrier is emotional eating. Most people with obesity claim that comfort eating is the root of their weight issues. And most therapists believe that it isn’t about food, it’s about feelings. They may be wrong.

Where emotional eating is severe, our person may have an eating disorder and they must not to try weight loss right now. Direct them to an eating disorder therapist. But moderate levels of emotional eating can be treated. This is not the place to describe how we deal with food cravings or undue attachment to foods like chocolate. Suffice it to say that person-centred counselling, dealing with trauma, childhood adversity or adverse attachments all have unsatisfactory outcomes for modifying eating that has little to do with hunger.

When you think about obesity therapy, let go of the notion that we are putting people on a diet or forcing them to change a lifestyle that they know and love, in which they feel comfortable and that is part of their larger system of friends and families. People who shout negatively about obesity therapy remind me of the saying it is the emptiest vessels who make the most noise. Come and see how the right obesity therapy can make a person flourish. Our next training, Essential Obesity, is coming this June. do itnow! https://eating-disorders.org.uk/professional-training/essential-obesity-psychological-interventions/

Discovering our clients with a lifeline

Posted on by ncfed

A PASSIONATE MILITANT SAYS NO

I hear on the grapevine that someone has taken exception to NCFEDs method for assessing a client’s story via a lifeline. The lifeline tracks their life experiences alongside changes to their eating and body size or weight with colours and pictures.

Someone claiming to be a psychotherapist has taken exception to our understanding the client’s weight changes during their lifespan (alongside their story) by calling this “fat phobic”

The apparent purpose of tracking a client’s weight, is not to shame or judge them. It is to see how life experiences and transitions have changed a person’s eating habits and weight status. The weight is important only as it serves as a communication of deeper issues that may be unspoken.

It was Freud who first identified the mind-body as a single energy system and both behaviour and body weight may symbolise issues that are either hidden from understanding or for which the client cannot find words to express or explain what is happening to them. As Van de Kolk explained, “the body keeps the score”.

Just as we understand that weight loss in the anorexic is the only way they know to experience an emotional pain for which they lack a language, it may be the same for weight change in the opposite direction. It is our sacred duty to identify ALL the signals in the client’s narrative to understand what is important to them, what has been lost or is missing, what is the communication that we need to hear. What have they been unable to cope with, and what can we learn about the deficits that therapy can address.

It can also be said that clients tend to like and find safe the lifeline process; in 40 years of work we have had no complaints. If anything, it shows that I am interested in who they are rather than simply their eating disorder symptoms. During the process they become curious rather than defensive. They start to make their own connections about a problem that has not been understood and that has plagued them  And they engage with me because they sense that I have seen them, and what is important in their life OTHER than food and body shape.

Some people are so wedded to their activisms that they are blind to reason. I am reminded that just because you have a loud voice you may not be right. They are passionate militants without fully understanding why.  Should they be let loose on vulnerable people?

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