to function at a high level. It can take upwards of two years just to break through denial. Even then, change is hard because they need the eating disorder to protect them from intolerable feelings. For chronic patients, the eating disorder is their identity, and contemplating the void created by giving it up is terrifying. Obtaining a history at each visit may be difficult, since the patient often doesn’t want to complain or admit to symptoms. They often avoid full disclosure or they outright lie. They use skin lotion to hide dehydration and sew weights into their clothing to falsify their weight. They may be totally accustomed to denying their bodies’ signals to the point of being unaware of physical symptoms. Asking, “Any problems?” is usually a waste of breath. It takes reading their body language to tell if “No, I’m fine” is the truth. Only by asking specific questions does one garner useful information. Their insight into underlying trauma, family dynamics and emotions is often totally repressed. They are delusional about their own weight, appearance, nutritional adequacy and how others view them. They often have a history of abuse, a dysfunctional family and/or a lack of an effective support system. They will walk out your door with no recollection of what you said, wondering how you tricked them into briefly seeing things in a different way. They are almost all hyper-vigilant, meaning overly sensitive to words, body language and perceived slights. They ascribe negative connotations to innocuous words and take them personally. There are also doctor factors that impede recovery. Doctors assume patients want to get better. We are trained to negotiate treatment approach with patients, not to cajole a delusional patient into wanting to nurture her/ himself. Doctors give orders and expect them to be followed to some degree, but should give up any notion that they are in control of these patients. It’s like the inability to “airplane” some food into a stubborn one-year-old’s mouth – No one can make people change behavior or ED patients get better. Here are some Do’s and Don’ts for
interacting with ED patients that I’ve gleaned over 30+ years of treating them. In some ways my approach differs from published literature, but my success rate has been better than what’s published also.
Demanding totally healthful eating and behavior right off the bat is way too overwhelming… • Do be kind. ED patients don’t need another control freak in their lives to abuse them. Suggest the minimum behavior necessary to stay out of the hospital. This motivates most patients, since hospitals take control of their behavior away from them. The “minimum” may consist of adequate non-caffeinated fluid, some salt, 600 kcal per day with portions from all the food groups and an agreement for no suicide attempts. Or a limit to the daily laxative dose. Or eating breakfast, no matter how big the binge was the night before. Demanding totally healthful eating and behavior right off the bat is way too overwhelming, impossible to achieve even for “normal” people and defeating. Having a patronizing authority figure threaten them with hospitalization only sets up a confrontational digging in of heels. Instead, reassure them that they should do all they can to stay compensated, but if they become medically unstable, we’ll do what it takes to stabilize them again. • Do demonstrate by your questions that you understand EDs and that everyone is different. They want to be understood. The stereotypical psychological pattern is one in which the patient has low self-esteem, often because of an emotionally “absent” parent (alcoholic, workaholic, abusive, narcissistic) or abusive environment. There may be a sense of loss of control, typically due to an overly controlling parent, inability to cope with conflicting demands, terror over pubertal body changes, or physical, emotional or sexual abuse. The family may overemphasize physical appearance or being seen as a “perfect” family, stifling emotional expression. Bulimics often have subverted anger, which they
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