Eating Disorders with Dr. Harry Brandt

Dr. Brandt is our guest, and he will be talking about eating disorders.

Bob M  Evening everyone. I'm Bob McMillan, the conference moderator. I want to welcome everyone to the Concerned Counseling website for our first Wednesday Night Online Conference of the new year. Our topic tonight is EATING DISORDERS. Our guest is Dr. Harry Brandt. He is the Director of the Center for Eating Disorders at St. Joseph's Medical Center in Towson, Maryland. St. Joseph's is one of the few Eating Disorders specialty centers in the country. Dr. Brandt is a psychiatrist. He's also a professor at the University of Maryland Medical School. Prior to his present job at St. Joseph's...he was, I believe, head of the Eating Disorders Unit at NIH (the National Institute of Health. So he has quite a bit of knowledge on this subject. Good Evening Dr. Brandt. Welcome to the Concerned Counseling website and thank you for being our guest tonight. Besides my brief introduction, could you please tell us a bit more about your expertise before we get into the questions.

Dr. Brandt: Sure....I've been involved in the treatment of persons with severe eating disorders since 1985. I have been both a researcher and clinician on a full-time basis. My current position involves the direction of one of the largest eating disorder programs in our region. I want to say good evening to everyone in the audience and thank you for inviting me onto your site this evening, Bob.

Bob M: To start off, because there is such a wide variety of people in the audience, what are eating disorders and how do you know if you have one?

Dr. Brandt: The eating disorders are a group of psychiatric illnesses that have, as primary features, severe alterations in eating behavior. The three most common disorders are anorexia nervosa, bulimia nervosa, and binge eating disorder. Anorexia nervosa is an illness characterized by starvation and marked weight loss. Persons suffering from this illness feel grossly obese despite being extremely thin. They fear eating to the point that they avoid caloric intake at all costs. Further, they often have a range of physical problems as a result of their illness and behaviors. Bulimia nervosa is characterized by episodes of significant binge eating, perhaps thousands of calories in an episode. Then, to counteract the binge episodes, persons with this illness will use various behaviors in an attempt to reverse the caloric intake. Self induced vomiting is common, but many people will use laxatives or fluid pills or compulsive exercise or fasting. Anorexic patients are at low weight., while bulimia nervosa can exist at any weight. Complicating the diagnosis is the fact that many anorexic patients will also pursue bulimic behaviors (approx. 50%). And many persons with bulimia nervosa will have wide fluctuations in weight as well. Both illnesses are highly dangerous with significant morbidity and mortality. The third major eating disorder is the most recently defined....binge eating disorder. This is similar to bulimia nervosa but without the compensatory purging behavior. Many of these individuals are at an above normal weight because of their eating pattern. In addition to the basics that I have outlined thus far...there are many associated features of each illness.

Bob M: Why does someone develop an eating disorder and is there anything new that's been uncovered in recent research as to the "why" question?

Dr. Brandt: There are many factors that are involved and I will highlight three major areas. The first is our culture. We are obsessed with thinness as a culture to the point where there is a tremendous emphasis on weight, shape, and appearance. This has increased through the decades, to the point now where just about everybody is worried about their weight. This even includes people who are at a perfectly normal or appropriate weight. As people attempt to manipulate their weight with dieting, they are at greater risk of developing one of these illnesses. The second factor that must be considered is a person's life history and underlying psychological issues from development. We see many common psychological themes in our patients with severe eating disorders. The final area I would highlight from the perspective of etiology or "why" is the biological arena. There has been an explosion in research about the control of hunger and fullness and weight regulation, and there are many important new developments in our understanding of these highly complex problems. Perhaps we can explore some of these in more detail this evening.

Bob M: What are the treatments for an eating disorder? And is there such a thing as a "cure" for an eating disorder? If not, is there a possibility of a cure in the future?

Dr. Brandt: The treatment of eating disorders begins with a diagnostic evaluation, and is guided by the nature and degree of symptoms and difficulties. A first step is to rule out any immediate medical danger in persons dealing with any of the eating disorders. Then, one needs to assess whether the individual can be treated on an outpatient basis, or whether a more structured, hospital-based setting is necessary. Often, persons with less severe eating disorders can be treated on an outpatient basis with some combination of psychotherapy, nutritional counseling, perhaps medication if indicated. If a person is unable to block the dangerous behaviors of the disorder on an outpatient basis, then we encourage the patient to consider inpatient or day treatment or intensive outpatient programs.

Bob M: Is there a cure though for an eating disorder, or one coming in the near future, or is it something that an individual deals with forever?

Dr. Brandt: Some patients do extremely well with appropriate treatment and may be considered "recovered." However, many will struggle with these illnesses for long periods of time. It is our hope that the treatment of these illnesses will continue to improve as we learn more about the causes and new therapeutic strategies emerge. I have seen tremendous strides in the past decade!! Also, there are a number of new pharmacological strategies. And psychotherapies are becoming increasingly refined.

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Bob M: Here are some audience questions Dr. Brandt.

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Hannah: Dr., I was wondering if my mitral valve prolapse could be the result of my anorexia and occasional bulimic behaviors? It started about 3 years ago.

Dr. Brandt: Mitral valve prolapse is a common problem. It is possible that it is unrelated to your eating disorder.....but it is also possible that your eating disorder is complicating the problem. I suggest you see your physician regularly.

Snowgirl: What do you do in the face of a relapse?

Dr. Brandt: Do not get discouraged. Eating disorders can be nasty illnesses, but if you keep trying you can overcome it. Also, reevaluate the treatment for eating disorder you are receiving if you are not progressing.

SS: What have you seen as the most successful course of therapy?

Dr. Brandt: I think the best treatments are multi-modality. Many persons do well with combinations of individual psychotherapy (eating disorder psychotherapy), nutritional counseling, sometimes family therapy and, if indicated, medication. Also, if things are not improving, consider inpatient or day hospital treatment.

Ragbear: I have been in recovery from bulimarexia since 1985--- when I had my last purge after 8 years (daily) active bulimia. I still battle low self-esteem (poor body image)... what can I do?????

Dr. Brandt: You should be proud to have conquered a difficult illness like bulimia. Now your attention needs to focus on what is behind your low self-image. Perhaps the self-image problem was the underpinning of your bulimia. I am sure that if you put your mind to it, you can figure it out.

CountryMouse: My question for Dr. Brandt is, what is wrong with NOT getting help for a "borderline" ed? I am a 36 year old woman, 5'3" and weigh 95 lbs. I have no real health problems due to my weight except for being cold all the time and dry skin. I definitely do not want to gain any weight, and think I can control my ed by staying at this weight. Also, I'm not really ready to admit that I have a problem, so I would need to face up to this before seeking treatment, right? I just don't want to gain weight.

Dr. Brandt: Obviously you DO recognize that you have a problem, or you would not be here. The bottom line is that a hallmark of anorexia is the massive denial that accompanies the illness. I have known many persons with so-called "borderline" illness who went on to have significant problems that could have been avoided if they had gotten the help they needed earlier. I suggest you face the harsh realities of your situation and get the help you need.

Bob M: Dr. Brandt, you mentioned earlier that there were some exciting new drug and psychological therapy treatments coming for treating eating disorders. Could you please elaborate?

Dr. Brandt: Certainly. The first point I would make is that the newer medications used to treat depression....such as Prozac, Zoloft, Paxil, and others are highly effective in the treatment of some patients with severe eating disorders. We are part of a multicenter study looking at a major antidepressant in decreasing relapse rates in bulimia nervosa and the results are quite promising. Further, the newer drugs can be used with greater ease in persons at low weight. From a psychotherapy perspective, there has been tremendous progress in dynamic psychotherapy, cognitive behavioral therapy, and group therapy techniques in the treatment of eating disorders. Additionally, we are using videotaping in expressive arts therapies to work on body image distortion.

Bob M: What are the names of these new drugs?

Dr. Brandt: The newest drugs that we are trying are mirtrazepine (Remeron) and the selective serotonin reuptake inhibitors, as well as the mood stabilizing agents (depakote, gabapentin, lamotrigine). Pharmacologic treatment of the eating disorders is complicated by the comorbidity that we see with anxiety, mood disorders, personality disorders, and other psychiatric illnesses.

Angela98: What about people who have symptoms of both anorexia and bulimia?

Dr. Brandt: Many individuals do have both symptoms. This a particularly serious form of eating disorder that requires intensive treatment approaches. One needs to pay attention to the dangers of starvation coupled with dangers of purging.

LD: I think that I have relapsed into my anorexia, because I don't want to eat. I am 96 lbs. and 5'3" and I am afraid of becoming even worse, but I am not sure I want to get better. How do deal with this? It is ruining my life, but it was so hard to deal with the first time.

Dr. Brandt: I think you have made an important first step. People with eating disorders are not happy DESPITE being at a low weight. The bottom line is that life can be a whole lot better if you take responsibility and face your illness. I have seen many recover through the years and it is very rewarding.

Bob M: There are some parents in the audience tonight who think their children may have an eating disorder. What is your advice to them, or a friend of a potential e.d. individual, in trying to approach them? The do's and don'ts.

Dr. Brandt: I think it is perfectly reasonable to approach a family member or friend if there is suspicion of an eating disorder. I think it is important to be direct, open, and honest with the person, but not judgmental. Parents often have to play a major role in helping their child get the treatment that is essential. It is probably better to focus on the way the individual is feeling as opposed to focusing on food, calories, weight, etc. I think it is tragic when friends and family stand by and avoid getting involved if someone they care about has a dangerous eating disorder. On the other hand, I have also seen situations where parents and/or friends get over-involved and forget that the patient has the primary responsibility.

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LostDancer: Dr. Brandt, if you are pregnant and have anorexia and/or bulimia, what could be some of the possible ramifications if the person would continue the behaviors of anorexia and/or bulimia through the pregnancy or at least for a while into the pregnancy?

Dr. Brandt: We have had several patients in this situation. It is essential that a person who is pregnant and dealing with an eating disorder get rapid and comprehensive treatment. The situation can be dangerous to both the patient and the baby and needs very careful monitoring. Nutrition is a critical element in all eating disorders, but particularly in this complex situation.

UgliestFattest: I have eaten 2 pieces of toast today and feel like I am grotesque for eating at all. Why can I not see what others see? I know what the scale says, yet I see something totally different. My scale says less than 100, yet I see a 1000 pound person when I look in the mirror.

Dr. Brandt: You are describing in detail the global distortion in body image that we see in persons with severe eating disorders. You need to face the reality that your mind is playing a nasty trick on you. You must not respond to these inappropriate messages from your mind, and instead, you must force yourself to take in adequate nutrition that is necessary to sustain you. Good luck.

Susan: Do you feel that antidepressants are helpful when treating eating disorders?

Dr. Brandt: Yes, the antidepressants are among the most important medications for eating disorders treatment. They have a primary impact in reducing impulses to binge and purge. And further, they are important because of the high rates of depression that we see in both anorexia nervosa and bulimia nervosa. Many of our patients are on these medications, and they benefit significantly.

rayt1: I am a 45 yr. old male anorexic with onset at 30. Have you run into any other such cases? I am 5'10", current weight of 100 and lowest at 68 lbs.

Dr. Brandt: Yes! We are seeing more and more men developing these illnesses. As our culture changes, some of the stereotypes of who develops an eating disorder have broken down. In the past, I think many men who had this illness were afraid to come forward because the illnesses were thought of as women's diseases. The bottom line is that eating disorders can affect just about anybody.

Bob M: Here's a great question from Lorin, Dr. Brandt:

Lorin: Dr. Brandt, Managed care companies are now getting tough with much needed medical hospitalizations when it is clearly needed when a patient is at 70 lbs. Where can someone turn for help when insurance won't pay and people can not afford the inpatient eating disorder treatment?

Dr. Brandt: This is a problem that we are confronted with on a daily basis. In Maryland, those without insurance can apply for Medical Assistance (Medicaid) and get help through this program. Also, there have been some research-based programs, where a person could get free treatment in exchange for participation in research studies. Unfortunately, there are not many resources. We work hard to encourage managed care companies to pay for treatment that is essential.

Bob M: Does the St. Joseph's Eating Disorder Center have a research program with free treatment? If so, how do people register or find out more about it?

Dr. Brandt: Our research efforts are all outpatient at the current time. 

Tammi: Is it possible to not practice bulimia for years, but not really be in recovery, meaning the problem was never really dealt with?

Dr. Brandt: Recovery is not simply not binging or purging, although this is an important first step. Recovery also entails more healthy attitudes about food, weight, and appearance.

Rosemary: My 19 yr. old college student overachiever daughter had a major disappointment, fell into depression, quit eating for a time and now is having trouble eating. She is not receptive to getting help. What can be done?

Dr. Brandt: I think it depends on her degree of illness. If she is significantly underweight, I think you need to become quite active in encouraging her to get the help she needs. If she says she is "ok", tell her that you would feel better if that was confirmed by a physician. If she is very sick, and unwilling to seek help, you might be forced to use the legal system to make sure she gets the help she needs. But this is only possible if physicians, or the courts, see her as an imminent danger to herself. I suggest you try to be direct, honest, and hopefully, persuasive.

Maigen: How does a physician "confirm" an eating disorder?

Dr. Brandt: The diagnosis of an eating disorder is made based on a comprehensive review of signs and symptoms, and a careful history taken by a skilled clinician. One needs to carefully review and assess a person's patterns of eating, and take a careful weight history with an eye toward family genetics.

Bipole: Well, I am bipolar II, and multiple personality disorder - dysfunctional background (incest), been in therapy. I've tried and tried to lose weight - sometimes I lose some, but I can't keep it off. When I fail on the diet, I get very suicidal. I'm almost afraid to try again -can't stand another failure. I am diabetic (2) with cholesterol through the roof. What can a person in this situation do to be successful once and for all? Thank you..

Dr. Brandt: A review of personality characteristics and many other factors is needed. Then, a person should undergo a complete physical and laboratory evaluation as well. We do not believe that dieting is useful to anyone. Our focus is on health- normal food intake- that is guided by a person's hunger and fullness cues. We also believe the focus should be on healthy nutrition and not on weight. Restrictive dieting tends to cause feelings of deprivation...and in the long range, only creates greater difficulties. Further, yo-yo dieting with wide fluctuations in weight causes significant disturbances in energy metabolism and is counter-productive.

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Bob M: Bipole, you might also need to be under a medically supervised program. You should contact your dr. about a referral.

Vandy: Are there any 1-800 numbers for people with eating disorders to call and talk to someone? I know they have them for suicide, depression, etc., but all the eating disorders hotlines I've found have to be paid for. I don't know about anyone else, but this makes me feel less important and I would really like something like that to be available.

Dr. Brandt: Yes, there are a number of organizations and 1-800 numbers. I don't have them in front of me.

AngelTiffo: I wanted to know what your opinion is on Peggy Claude Pierre's treatment?

Bob M: While you are answering that question, maybe you could tell us briefly what the thesis of that book and her method of treatment is, Dr. Brandt?

Dr. Brandt: I believe that Peggy Claude Pierre's treatment is unproven. There has been tremendous interest in her treatment since she appeared on 60 minutes a couple of years ago. The thesis of her treatment as I understand it, is that, she and her staff tends to take over many of the functions for patients with severe anorexia. She was noted to hold and cradle patients during her appearance on TV. She seems to focus on "reparenting" of persons with severe eating disorders. What is notable is that she has made fantastic claims....but has not allowed her claims to undergo scientific scrutiny by the experts in the field. I have concerns about the regressive nature of the treatment, and concerns that many patients will have significant difficulty after the treatment. Further, I was quite concerned that Princess Diana had turned to her for advice about her eating disorder, and that she went public with that information after Diana's death. That seemed to me to be ill-advised, inappropriate, if not unethical. Overall, there have been many claims that have not been substantiated. Our view is that the patient with a severe eating disorder needs to be an active, collaborative participant in the treatment process. We try as best we can NOT to take over for the patient, but rather, to engage the patient in a collaboration.

Bob M: Regarding that: here's a comment from an audience member...

Dickie: Makes it hard to trust any doctor.

Dr. Brandt: Dickie, I think many physicians are highly ethical and trustworthy! Of course, I may be biased.

Trina: Dr. Brandt, in regards to the "regressive nature" of Peggy Claude Pierre's treatment - wouldn't it be effective psychoanalytically to regress?

Dr. Brandt: I believe many people who suffer ED's do want doctors to take responsibility for their eating disorder treatment. It's quite hard to collaborate in treatment when one is clueless and helpless? Yes, but regression in psychoanalysis is different from what Ms. Claude Pierre is doing. Psychoanalysts encourage patients to speak their thoughts freely, and patients might regress. But there is not the active encouragement to regress in the way that Ms. Claude Pierre seems to be encouraging. The psychoanalyst maintains neutrality. I agree....many patients do want the physician to take over, but that does not mean the physician should do so. The reality is that the physician must encourage autonomy.

LJbubbles: I want to know what the symptoms are of a relapse and also, if you have an anorexic in your family is it possible to 'pick up on' some of their symptoms.

Dr. Brandt: Relapse symptoms include restrictive eating, trips to the bathroom during and after meals, social isolation and withdrawal, depression, obsessive focus on weight and appearance, etc. Regarding "picking up symptoms" from family members, if you are healthy, the answer is "no".

Pele: I just spent 2 weeks at a seminar in London. Things (as far as the ED were concerned) were fine. Now that I have returned home, I have fallen into the same bulimic behaviors and thought patterns. Why was I okay there, but here I can't keep that up?

Dr. Brandt: There are perhaps many reasons for your difficulties. Perhaps there are stressors at home you were able to escape while in London.

Livia: I feel that eating disorders has something to do with control. Is there any pattern among the ones that have binge disorder?

Dr. Brandt: I agree that eating disorders often do center on feelings of control or lack of control. We see themes in our patients of difficulties in this arena.

Lonely: Can you ever fully recover from an eating disorder--with out relapse?

Dr. Brandt: Yes, I have seen many people with rather severe eating disorders manage to build the necessary psychological structure and supports in the outside world to fully recover from an eating disorder.

MikeK: What one book would recommend that a parent of a child with an ED read?

Dr. Brandt: I would recommend reading "The Golden Cage" by Hilda Bruch.

Maigen: If you are restricting your calories, such as avoiding all foods with fat, and not going on "typical" binges, but you are purging, does this make you both anorexic and bulimic, or just bulimic? What is your opinion?

Dr. Brandt: The "label" or "diagnosis" is not what is important here....what is important is that the pattern of eating behavior that you describe is of serious concern. I suggest you get help from a professional.

Bob M: It's getting late, here's the last question Dr. Brandt...and let me say at this point, I really appreciate you coming onto our site this evening. I know you can't see it, but the audience has sent me many comments on how much they have learned from this discussion. Also, FYI, because I'm getting a lot of questions on our online counseling groups that start in February. Here's the final question Dr. Brandt:

Jen: How do you know when it is time for inpatient therapy?

Bob M: And by the way Dr., how long does it take for a person to "overcome" or deal successfully with an eating disorder?

Dr. Brandt: There are a number of factors in evaluating someone for inpatient: 1. Failure of access to a well designed outpatient program; 2. Severe metabolic (physical) abnormalities; 3. Rapidly progressing weight loss which is not reversing on an outpatient basis. Ongoing progressive binging and purging, with danger of electrolye (elements in blood) disturbance; 4. suicidal risk or progressive depression; and, 5. Limited family support or structure. These are some of the factors we use in making this complex decision. Before I sign off, I'd like to thank all who attended and asked such fine questions. I've really enjoyed being part of this interesting format. Thanks!!!!

Bob M: Thank you again Dr. Brandt for coming and for staying late like this. We appreciate it. And I want to thank everybody in the audience for coming tonight and participating. I hope you got something out of it. We hold these topical mental health chat conferences every Wed. night at the same time...so please come again. Thank you for coming tonight Dr. Brandt. Good night everyone.

Dr. Brandt: My pleasure Bob. I hope to be invited back soon.

Bob M: Good Night everyone.

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