- [Jeff] Welcome to "Healthy Minds."

I'm Dr. Jeff Borenstein.

Everyone is touched by psychiatric conditions, either themselves or a loved one.

Do not suffer in silence.

With help, there is hope.

Today on "Healthy Minds" - Anorexia nervosa is a serious psychiatric illness, and it has biological underpinnings.

So if anyone ever thought that this is a passing phase or that someone will grow out of it, I just encourage people never to think that way, because if you don't act the likelihood is actually that it's gonna become more severe, not that someone's gonna grow out of it.

- That's today on "Healthy Minds."

This program is brought to you in part by the American Psychiatric Association Foundation and the John and Polly Sparks Foundation.

Welcome to Healthy Minds.

I'm Dr. Jeff Borenstein.

Eating disorders can be the most complicated of conditions to treat, and if left untreated, can potentially result in death or serious medical problems.

Today I speak with leading expert Dr. Cynthia Bulik about eating disorders.

(gentle music) Cindy, thank you for joining us today.

- Thank you so much for having me today, Jeff, it's great to be here.

- I want to jump in and have you tell us about eating disorders, tell us about the most common eating disorders what they are, what they look like, and then we'll start to talk about some of the treatment as well.

- Sure, well, I'm gonna go in reverse order, because it seems like people tend to go with the most visible eating disorder first.

So I'm gonna start with binge eating disorder.

Binge eating disorder is a condition where people engage in binge eating, and the definition of binge eating is eating an unusually large amount of food, in a circumscribed period of time, but that's coupled with a sense of loss of control.

So once you start eating, you just can't put the brakes on, and that's the primary symptom of binge eating disorder.

The second disorder in the family of eating disorders is bulimia nervosa, and like binge eating disorder, that includes episodes of binge eating, but they come packaged together with some sort of compensatory behavior or something to undo the effect of the binge.

And that can be self-induced vomiting, it can be laxative abuse, it can be excessive exercise, it can be fasting or going for long periods of time without food.

So the difference between those two is really the presence of those compensatory behaviors.

Now, the most visible eating disorder, and I think the one that almost everyone has heard about is anorexia nervosa.

And this is the disorder that's marked by extreme food restriction and/or increased energy output, so excessive exercise.

But that results in extremely low weight and that is sort of the classic picture of anorexia.

What we're coming to realize, however, is that that syndrome, that sort of restriction of intake and increased exercise, can actually occur in people of all shapes and weights.

So right now we're calling this atypical anorexia nervosa but it's all the signs and symptoms of anorexia nervosa except that low body weight.

Those are sort of the big three, but I'm gonna give you one more, just to round out the family.

And that is avoidant restrictive food intake disorder.

Now again, people have thought that this primarily affects children, but in actuality, it can hit across the age span.

And this is what used to be known as extreme selective eating, or in more lay terms, extreme picky eating.

But to the extreme, where it can influence growth and development, it influences social interaction, it can actually lead to malnutrition.

And this is something that we're starting to see a lot more of in the literature now.

And that's pretty much the landscape of the eating disorders.

- Excellent overview.

Let's start with a little bit more detail about anorexia nervosa.

In many ways, one of the most dangerous psychiatric conditions, both from the physical sequelae, and also the risk of suicide.

So tell us about that.

- I need to emphasize what you just said and say that anorexia is a serious psychiatric illness, and it has biological underpinnings.

So if anyone ever thought that this is a passing phase or that someone will grow out of it I just encourage people never to think that way because if you don't act, the likelihood is actually that it's gonna become more severe, not that someone's gonna grow out of it.

And you are right on target.

Anorexia has one of the highest mortality rates of any psychiatric illness.

And the reasons for the mortality are first, the extreme restriction or starvation.

The body is basically in a starvation state and that can lead to death, it can lead to multi-organ failure, it can lead to heart attacks, but also suicide.

And I think that's often overlooked.

And one of the things that we've seen in some of our studies is that when people with anorexia nervosa attempt suicide, the way they attempt is actually highly lethal.

So unfortunately, there are a high percentage of people with the illness who do die by suicide.

- What are the early warning signs and symptoms?

'Cause as you said, early treatment is the best thing possible.

What are the early warning signs that people can look for?

- And this is one of those things where it's always tricky to say what's normative and what pushes someone over that line where it really does impair with their life or their functioning or their families.

For youth with an eating disorder.

So for example, if you're a parent and you start seeing that your child is sort of cutting back on foods or skipping meals or saying, oh, you know, I had a big lunch or I ate at my friend's house, for lunchtime and I'm really hungry for dinner.

So just sort of like quietly moving away from the family's meal pattern.

That's one of the things where your antenna should be going up a little bit.

And of course sometimes that happens and it's normal.

But if it becomes a pattern, if you start noticing it, then it's something that you want to dig a little bit more deeply into.

And one of the things that I think is very concerning and difficult for family members to deal with, is if your child, for example, starts making changes to their diet or their behavior, that on the surface seem that they might be healthy.

So they may decide, I think I'm gonna become a vegetarian, or I think I'm gonna cut out red meat.

We hear this all around us all the time, that these are healthy steps to take for your own cardiovascular health, right?

But when it takes that step to becoming an obsession, to be something that is very rigid, to be something that they have no flexibility with at all, then you have to start thinking about, hmm, maybe this pattern is becoming entrenched and maybe it is one of those first steps down that slippery slope to anorexia nervosa.

- And if a parent is seeing that in their child, what should they do?

- Jeff, that is such a critical question.

And one of the things that we have heard is that it's easier for parents and teachers and professors to talk to their students about depression, about substance use, about any other psychiatric disorder, than it is about eating disorders.

And they're afraid of commenting on their weight.

They're afraid to say, "Hey, you look like you might be getting unhealthy."

But we still have to do it.

And it has to come from a place of compassion, you have to let them know that you care, that you're concerned about some of the things that you're seeing and that you wanna help.

And be prepared for denial.

Because what you have to remember is that in many ways, anorexia nervosa is a defense against anxiety.

And I'm gonna go down that path for just a minute so I can clarify what I mean.

So people who develop anorexia, often say to us as clinicians that starvation actually decreases their baseline anxiety.

So they tend to be pretty anxious people at baseline.

And somehow going on that first diet or having that first experience of caloric restriction gave them a sense of calm, both psychological calm, but also sort of biological calm, they didn't feel as aroused or anxious.

And if you raise the question to them or if you present your concerns and say, I'm really worried about you, and I think we should get some treatment, they might feel like you're taking that away.

And that might be the one way that they deal personally with anxiety.

So one of the things that we're always thinking about is not just taking that away, but replacing it, replacing it with other tools, other ways that they can deal with that underlying biological and psychological anxiety that they feel.

- So you wanna A, replace the treatment, quote unquote, of that anxiety with a healthy coping mechanism.

And the other thing that I think is important for people to realize, that this is an illness so somebody doesn't decide, oh, I'm gonna be uncooperative and not eat properly, this is an illness that is beyond their control without help, and they're not doing it to misbehave, so to speak.

- No, this is not an intentional behavior pattern.

And in fact, so many parents that I've spoken with and worked with will say that on one day they felt like they could reach their child and they recognized their child, and then it was almost like a switch went off and the next day they were really transformed and they couldn't reach them anymore, they couldn't sort of talk sense with them anymore.

And that's the point at which their child has been replaced by anorexia nervosa.

And I think a lot of parents really benefit from sort of stepping back from saying what happened to my child?

To saying, hmm, that's not my child talking right now, that's the anorexia nervosa talking right now.

Separating those two things out allows you to preserve the love and the care that you have for your child while recognizing that the thing that you really need to work against is the anorexia, not your child.

- Tell us a little bit about the treatment.

So somebody goes in for an evaluation, they have the diagnosis, what's next?

- A lot of the treatment plan will depend on the state of the person when they come in from an evaluation.

So especially for youth, many, many children and adolescents with anorexia nervosa can be treated on an outpatient basis, using the evidence-based treatment of choice, which is family-based treatment, or FBT, as it's known in our field.

And this is basically a treatment in which the parents and the child both come into treatment, and sometimes other family members as well.

And parents really take over control of their child's eating.

And the the treatment empowers parents to do that, because if you remember what I was saying before about this switch, anorexic nervosa has a very strong personality, and it can actually sort of tamp down the power of parents in order to actually do the things they need to do as parents.

So it's re-empowering them to feed their child appropriately and adequately to gain and maintain weight.

As that treatment progresses and as the child gains weight, then gradually that control is given back to the child, to be able to prove that they can actually do this on their own.

But that whole course of treatment can often happen on an outpatient basis and as I said, is the evidence-based treatment of choice for youth.

Now for adults with anorexia nervosa, honestly it's a lot more difficult, and in part, because we don't have that same developmental structure where we can bring the parents into treatment and really have them take over treatment.

So in those situations, and sometimes with youth as well, if their weight is very low and if FBT is not working, or is not suitable for one reason or another then inpatient re-nourishment is essential.

And that basically is an inpatient hospitalization, or a partial hospitalization, or residential care, that allows the person to be re-nourished under a doctor's care.

But, and I think this is really important regardless of whether we're talking about FBT, or inpatient treatment, re-nourishment is just the important and essential first step.

Recovering from anorexia nervosa isn't just gaining weight, but the weight gain is essential to be able to do the hard work of psychotherapy.

Starvation messes with your brain and it's really hard to do psychotherapy with someone who is starved, but boy, do they need support during that re-nourishment phase because it's challenging, it's a difficult, and it can even be physically painful for them to be re-nourished - In many ways, when the weight loss is happening, it becomes a snowball effect as time goes on as the person moves into starvation, as the treatment begins, as they're beginning to be re-nourished there could be a snowball effect towards the positive in terms of treatment, but you gotta get to that point first.

- It's hard, it is hard work.

And one of the things that we don't completely understand is why we often need to feed these folks so many calories in order to gain weight.

Their engines are just burning up energy while they're being re-nourished, and it's almost like just having to keep putting gas in the tank to keep the car going.

And all of our equations, you know, normally we can predict how many calories a person will need in order to gain a pound or lose a pound, but those equations all go out the window during phases of treatment, that we call a hypermetabolic stage.

And that's that stage when their engine is just like burning like crazy, and we're feeding them a lot of food, but they're not gaining weight, the body's not holding onto it.

And that's something we really need to understand better so that we can tailor that re-nourishment phase to individual patients, not just work on sort of like global equations to predict what a person needs in order to gain weight.

- I want you to tell us a little bit about bulimia and what that entails, what happens to people who are experiencing that condition?

- Sure, so if we go back, bulimia is that combination of binge eating plus compensatory behaviors.

Sometimes this might happen occasionally at first, so a person might have one binge or a couple binges.

And then typically what happens is the purging then comes to counteract the effect of the binge.

And I think I need to sort of put this in context a little bit for our viewers.

Everybody has overeaten at some point and I often use Thanksgiving as an example of when people tend to eat beyond their point of fullness or beyond their point of satiety.

So we know that feeling, but you gotta multiply that by a couple orders of magnitude to understand what it means to have bulimia and be out of control and unable to stop binge eating.

It really is like once the train's out of the station, there's just no way to put the brakes on, unless they're sort of interrupted by someone or sometimes they develop severe belly pain.

And then all of that distress is often associated then with how do I get rid of this feeling?

How do I undo the effect of that binge?

Because also underlying that is the concerns about weight gain.

So all of these disorders have concerns about physical shape and weight and the gain of weight.

So in some way sort of undoing the caloric effects of the binge as well.

And so that purge is relieving in that it takes away the bad feeling of the binge but then that's only temporary, because then they start feeling guilty about that as well.

And we saw that during the pandemic as well, that people then started feeling guilty about wasting food, especially when we were concerned about food chains, or for people who actually are food insecure or insufficient, that can be a real sort of guilt inducing part of the eating disorder as well.

I just ate food that we don't have enough money to really purchase or this is gonna impact the rest of my family because I've binged on what we have in the fridge.

Both binge eating and purging carry significant physical risks.

And I think that's what you were really interested in, it can affect your esophagus, it can affect your teeth, it can lead to heart attacks, all of these physical symptoms.

And lots of long-term gastrointestinal problems, even with people who have recovered from the illness, because these just aren't behaviors that our body was really designed to do repetitively.

- I'd like you to tell us about the causes, and the combination of genetic, environmental, and other, and I know you've done a lot of work, a lot of research in this, tell us about the causes of these conditions.

- So we know from years of twin studies, and now molecular genetic studies, and genome-wide association studies where we're looking at the whole genome of people with these illnesses in comparison to the whole genome of people who've never had these illnesses, that there is a marked genetic component to all three of these eating disorders, anorexia, bulimia, and binge eating disorder.

And in fact, there's a study that'll be coming out that shows that ARFID, or avoidant restrictive food intake disorder is also highly heritable.

So I'm comfortable in saying that all of the eating disorders have a genetic component, but importantly it's not all genetics, and these are classic psychosomatic illnesses, right?

They're right on that border of the mind and the body and we've gotta pay attention to both.

And the other border that they're right on is genes and environment.

Because we all vary in our genetic risk for eating disorders, but we also vary in our exposure to environmental risk factors.

- I'd like you to tell us about the research that you've been involved in that really has shown, looking at the genetics and clinical syndrome, the relationship between the eating disorders and some of the other co-occurring psychiatric conditions and also the relationship between eating disorders and metabolic syndromes as well.

- This is sort of where we are right now in understanding the biology and the genetics of these illnesses.

And most of the data we have at this point are on anorexia nervosa, so I'll focus on that.

What we've found, through a series of genome-wide association studies, that are getting larger and larger, because the trick with these studies are to have as many people with the illness as we possibly can to pull all the information together so we can identify these genetic variants that influence risk.

It's so easy to misinterpret genetic science.

We all learned in our basic biology classes about those single gene traits, right?

This gene causes this, it's not like that at all.

We're actually anticipating that we're gonna find hundreds, if not thousands of genes, that work in concert to increase risk.

And just reminding everyone, in combination with environmental factors, it's a complex trait, it's a complex illness.

And I think as humans we really want things to be more simple, but in these situations, we really have to embrace the complexity and think more broadly than just a simple, why, why not?

Yes.

No.

The really interesting thing about this is we anticipated that there were gonna be strong positive genetic correlations with psychiatric disorders.

What we didn't anticipate was that we were gonna see those same types of genetic correlations only with metabolic traits, with obesity, with HDL cholesterol, with lipids.

Now what's really interesting about this is these correlations, with the exception of HDL cholesterol, the good cholesterol, were in the opposite direction.

So the same genes that increase your risk for anorexia nervosa actually decrease your risk for developing obesity or for developing type two diabetes.

And we hadn't really put together, in the past, that there might be a metabolic component to anorexia Noosa, although we always asked ourselves how can these people actually lose that much weight when the rest of the world has difficulty losing just a few pounds and keeping them off?

So we probably should have asked ourself that question sooner.

But the strength and the persistence of those correlations have gotten us to the point where we're saying, you know, actually anorexia nervosa, is both a psychiatric and a metabolic disease.

And maybe one of the reasons that we're not so great at treating it is that we focus more on the psychiatric side and not enough on the metabolic side.

So I think there's a little bit of a revolution happening in our understanding of anorexia nervosa.

And I think when we have the same data from bulimia and binge eating disorder, we're also gonna see a metabolic component, although not the same metabolic component that we see in anorexia.

- Well, I think having a revolution makes a lot of sense 'cause although we have effective treatments now, we need more effective treatments that'll help more people sooner.

So thank you for your part in that revolution.

- You're welcome.

- Before we finish up, if somebody's watching right now, and either they themselves have an eating disorder, or their loved one does, what do you say to them?

- I say, regardless of your age, regardless of your sex, regardless of your gender, regardless of your size, help is available and there is hope.

And I think that's one of the messages that we need to make sure we package with our genetic information.

Just because there's a genetic component to these illnesses, that doesn't mean they're not treatable, that doesn't mean you're destined to be ill for the rest of your life.

We have treatments that work, and the trick is to get the courage.

And I think courage is an important word, to step out, to seek treatment, to say, hey, I know something's amiss and I'm asking for help.

And if for some reason, especially, if you don't fall into that stereotypic sort of age and gender of someone who has an eating disorder, because there is no accurate stereotype.

If the first physician that you reach out to, for example, says something dismissive or says something like, oh, men don't get eating disorders, or you're too old for an eating disorder, you don't have to educate them.

If you feel like it, you can educate them, but find someone who does understand.

And I think there are a lot of resources out there, in the National Eating Disorders Association, the National Center of Excellence for Eating Disorders, the Eating Disorders Coalition, where you can find real solid, accurate information about where to find practitioners who understand and who will listen and validate your experience.

And dig in, get that courage and take someone with you, find a trusted friend or a parent or anyone who you can confide in and say, you know, I'm afraid I might back outta this.

And have them give you that little extra push and support that you might need in order to reach out for care.

- Cindy, such good guidance.

I want to thank you so much, first of all for the work that you've done over so many years and the work you're continuing to do on this important topic.

And thank you for joining us here today - And thank you for talking about eating disorders on your program.

Thank you, Jeff.

(gentle music) - If you're experiencing an eating disorder, do not suffer in silence, seek help.

And if a loved one of yours is experiencing an eating disorder, help them receive the treatment that they need.

Remember, with help, there is hope.

(gentle music) Do not suffer in silence, with help, there is hope.

This program is brought to you in part by the American Psychiatric Association Foundation and the John and Polly Sparks Foundation.

(gentle music)