Eating Disorders Recovery with Dr. David Garner

Bob M: Good evening everyone. I want to welcome everybody here tonight for our Eating Disorders Recovery Conference. Everyday, I get emails from those of you with eating disorders talking about how difficult it is to recover from them. You talk about trying, you talk about getting therapy and relapsing and I want you to know that is not that unusual. Recovering from eating disorders can be a long, difficult and trying process. Our guest tonight is one of the top researchers of eating disorders in the country and we'll be discussing why it's so hard and what you need to know to make your recovery longer lasting and more effective. Our guest is Dr. David Garner, Ph.D. Dr. Garner is the Director of the Toledo Center for Eating Disorders. He has published over 140 scientific articles and book chapters and has co-authored or co-edited 6 books on eating disorders. He is a Founding Member of the Academy for Eating Disorders, a scientific consultant for the National Screening Program for Eating Disorders and a member of the Editorial Board of the International Journal of Eating Disorders. Good evening Dr. Garner and welcome to the Concerned Counseling website. I'd like to start with the question: Why is it so difficult for people with eating disorders to make a full and lasting recovery?

Dr. Garner: Thank you for the introduction. This is a difficult question since there are many reasons for failure to recover; however, most significant is the conflict about weight and weight gain.

Bob M: And what is that conflict?

Dr. Garner: Most people with eating disorders suffer from the "anorexic wish"- the wish to recover but not gain weight. This leads to continued attempts to suppress body weight which leads to increased urges to eat. The key to breaking the cycle is becoming a strong "anti-dieter" - a real problem for those who fear weight gain.

Bob M: Before we get into how to accomplish that, I want to also have you touch on the other reasons for failure to recover.

Dr. Garner: Sometimes the eating disorder is a comment on dysfunctional family international patterns and as long as the patterns continue to exist, recovery is difficult. For instance, the problems in recovery may relate to a trauma, such as sexual abuse, and until this issue is dealt with, recovery is impeded.

Bob M: So is that one of the reasons for failure to recover from an eating disorder...that the issues that led up to it haven't been dealt with completely?

Dr. Garner: That is correct. Another one is that the simple wish to maintain a low weight is in conflict with the biological realities related to the person's set point for body weight and this is simply not accepted and the person continues to diet. This may seem like a straight forward issue, but for women in our society, it is very difficult to accept a body weight higher than one would like.

Bob M: Is it possible then to effectively work through your eating disorder while at the same time dealing with the abuse, or other issues, that may have lead up to it? Or to be really effective, should one work through the other issues before tackling the eating disorder?

Dr. Garner: The order of dealing with the issues varies. Usually, one needs to work on both at the same time. In all cases, it is impossible to make headway on the psychological front while continuing to engage in symptoms. Bingeing and vomiting b/v and strict dieting alter your perceptions so much that it is impossible to work on other issues.

Bob M: At the beginning of the conference, I mentioned that those who have relapses along the way, should not feel alone. What does the research say about the number of people who try and recover and have a relapse...and what are the average number of relapses a person experiences?

Dr. Garner: The percent of people with bulimia who recover at a 7 year follow-up is about 70% with another 15% making significant progress. With anorexia nervosa (AN), there is less research and the treatment phase is longer, but 60-70% of patients recover with treatment from a high quality eating disorders treatment facility. Many patients recover after quite a number of relapses.

Bob M: What is the best form of treatment when it comes to making a significant or lasting recovery?

Dr. Garner: The best studied treatment for both Anorexia and Bulimia is cognitive behavioral treatment (talk and behavioral modification therapy). However, for patients under 18, family therapy must be part of whatever treatment is offered.

Bob M: We get many questions here Dr. Garner from folks who want to know, is hospitalization the most effective way to deal with an eating disorder, followed by intensive outpatient therapy or can you just get therapy on a weekly basis?

Dr. Garner: I do not think that hospitalization is necessary or desirable for most patients- intensive outpatient treatment or day hospitalization has replaced inpatient treatment for the most part. Most bulimic patients benefit from outpatient therapy and severe eating disorders usually require something more than weekly, outpatient therapy.

Bob M: Here are some audience questions:

Rhys: How does one become a strong anti-dieter and not gain weight? It seems like an oxymoron.

Dr. Garner: It is, that is why most people decide on some level to opt for trying to continue to suppress their weight. Modest weight gain may occur even in treatment for bulimia.

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Peppa: What if you really have no other issues and the eating disorder is just in you? Do you think some people may be just born with it and that it can't be cured?

Dr. Garner: I do not believe that. Most people with eating disorders can do very well with treatment. There is little evidence that it can't be cured, if you are willing to follow the advice provided in quality treatment.

Bob M: This is the second time you have used the term "quality treatment". What does that mean exactly?

Dr. Garner: It means treatment that emphasizes both the nutritional rehabilitation as well as dealing with psychological issues. This does not mean, encouraging patients to restrict their food intake to low levels of calories (e.g. 1500) or having them avoid sugars or flour or assuming that their eating disorder is an "addiction".

livesintruth: Do you think that family therapy should be part of the eating disorder recovery process for just those under 18? What do you recommend for those 19-25 year olds who are working through the developmental issues of separating from their parents? What is the best way to help parents understand what is happening? Often the person with the disorder is stuck having to tell their family alone. So how do they go about telling them in order that they can believe her and support her?

Dr. Garner: I agree that family therapy should not be limited to those below 18 yrs- it is just that it is mandatory for those who are living at home or who are financially dependent of their family. Family therapy for those 19-25 can be very helpful.

Donnna: Dr. Garner has touched on an area that I am dealing with now. I have uncovered some severe trauma in my childhood years well into my teens. Could this be the reason I have been dealing with this eating disorder for 26 years? Although I have been in a recovery program since April, I feel like this will never end. It's almost as if it has gotten worse than better. Why is that?

Dr. Garner: Often an eating disorder gets worse when the traumatic issues are uncovered; however, this should subside soon. Treatment should assist you in identifying the issues and then, move beyond them.

Shelby: What if your parents pretend as if everything is fine...they don't seem to care whether you skip meals or not?

Bob M: While Dr. Garner is answering that, I want to mention that Shelby's situation apparently isn't unusual. I get about a dozen emails a week from teens asking what to do because their parents don't believe them, even though the person tells them they've got an eating problem.

Dr. Garner: Then there is something wrong with your parents. Would they do the same thing if you were taking drugs, engaging in other self-harm?? Why are they appearing to be so unconcerned? What do they tell you?

Bob M: Let's take it at face value, Dr. Garner, that the parents are in denial. What is a teenage child to do then to get help?

Dr. Garner: Unfortunately, parents can be inept and it is unfortunate that you are suffering. It is possible to consult school counselors or sometimes, even if parents are in denial, they will agree to allow their teenager seek treatment. Don't let you parents' difficulties discourage you from seeking treatment.

JerrysGrlK: What about people over 25 with a eating disorder? How do you overcome the fear and take the first step to get help?

Dr. Garner: Knowing that eating disorders can be cured is reassuring. You are not alone. A phone call to an experienced therapist, just to ask about what treatment involves, is the first step.

twinkle: We are dealing with Dissociative Identity Disorder/Multiple Personality Disorder and was wondering do you have any advice on how to approach the eating disorder while dealing with so many other issues or should we just wait until we have dealt with the other related issues?

Dr. Garner: As I said earlier, it is impossible for you to make headway with the personality disorder or other significant problems as long as you are bingeing or vomiting or starving. Some people find that their so-called personality disorder goes away once they stop the aforementioned symptoms. So, tackle the eating disorder and see what is left.

Bob M: Here are some audience comments to Shelby's earlier statement about her difficulty in getting her parents to help her:

pumpkin: But what happens if even the counselor can't get through to a parent. I know that happened to me and I felt as though maybe there really wasn't anything wrong with me and I got worse.

livesintruth: I'm sorry, but it just isn't that easy Dr. Garner. I personally have experienced that naivety of parents with children who have eating disorders and other mental health problems. There are some parents out there unfortunately who do not let their children get help. They don't encourage them. The parent-child bond is so strong, usually stronger than the bond between the individual and the eating disorder, that individuals will begin to believe their parents' denial.

HelenSMH: Some parents think that it's just phase. How does one make the parent understand that it's not "just a phase"?

Bob M: I think there's only a limit as to what one can do when they are underage. My suggestion would be to speak with a school counselor, someone associated with your church or synagogue, call your family doctor. See if these people will call your parents and try and make an impact. Dr. Garner just sent me a great comment: "How do we make parents competent?" That's for another conference. Is there is significant difference in the way anorexia and bulimia are treated, Dr. Garner?

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Dr. Garner: I agree, I think that there are people out there whose interest is in helping children, even if parents won't. (to earlier comment). Now I will tackle your question. Anorexia and bulimia nervosa share many features in common, so it is not surprising that approaches to therapy for both disorders overlap to a significant degree. Common approaches are recommended for both disorders to address characteristic attitudes about weight and shape. Education about regular eating patterns, body weight regulation, starvation symptoms, vomiting and laxative abuse, is a strategic element in the treatment of both disorders. Finally, similar behavioral methods are also required, particularly for the binge eating/purging subgroup of anorexia nervosa patients. Nevertheless, there are differences in the treatment recommendations made for these two eating disorders. This may partially reflect differences in the personalities, background and training of the main contributors to the literature for these two eating disorders. However, key distinctions can be made between these disorders based on motivation for treatment and weight gain as a target symptom, both requiring variations in the style, pace, and content of therapy.

Bob M: So then, the key question, if weight concerns are the major issue, and people with eating disorders always talk about the "voices" they hear about how "fat" they are, what is the most effective way of ending those concerns. What should people who want to recover be concentrating on when it comes to that issue?

Dr. Garner: The topic of body weight is approached from an entirely different perspective for anorexia and bulimia nervosa. Experts in the treatment of bulimia nervosa recommend that bulimia nervosa patients should be told that in most cases treatment has little or no effect on body weight, either during treatment itself or afterwards. In anorexia nervosa, this reassurance is not available since weight gain is a major aim of treatment. The significance of this contrast cannot be overemphasized. I do not know how to actually make those voices go away. The first study I did 20 years ago attempted to solve this. Rather, you need to ignore the voices, kind of like a color blind person learning to ignore false signals about color.

Bob M: And when a person feels a relapse or difficult period coming on, what are the most effective ways to deal with that?

Dr. Garner: It should be stressed that vulnerability to eating disorder symptoms can continue for many years, even if there is recovery from eating symptoms. A valuable strategy in avoiding relapse is remaining alert to areas of potential vulnerability. These include vocational stress, holidays, and difficult interpersonal relationships as well as major life transitions. Patients may become distressed if they continue to gain weight. They may also be vulnerable during pregnancy. Patients without any overt symptoms may remain quite sensitive about weight and shape. They need to be prepared for encounters with people who may have seen them at a low body weight. During the termination phase of treatment, patients need to practice adaptive cognitive responses to well intentioned comments like "I see you have gained weight" or "my, how you have changed". Patients may even need to be prepared for occasional callous comments about their weight. Vulnerability to relapse increases during periods of psychological distress. Susceptibility to relapse may also increase with positive life-changes and enhanced self- confidence. Fresh relationships, career advancement, increased physical fitness and overall improvement in self-confidence can activate latent beliefs like "now that things are going so well, maybe I can lose a bit of weight and things will be even better". Patients need to be reminded that weight loss is enticing and insidious in its effects. Initial results may be positive; however, the adverse impact on mood and eating are inevitable over time.

OMC: Why do you think there is no cure for such a deadly disease as anorexia, although it has been researched for generations?

Dr. Garner: Many patients do completely recover from anorexia, just like with other disorders. It has only been carefully researched for the past 20 years.

ZZZ I SHOULD DIE: Which type of eating disorder would you say is the hardest for a person to recover from?

Dr. Garner: Anorexia-- when the person is at a very low weight and is B/V. Starvation effects make it very hard to relate to others and to focus on any aspect of treatment.

Bob M: Here are a few audience comments, then we'll continue with the questions:

Latina: Thank you for making that point Dr. Garner regarding eating disorders being viewed as an addiction. So many individuals with these disorders seem to sell themselves out to the fact that it is a disease or an addiction and that they are untreatable. I understand Donna's point very much. Even recently, I have had family members say that I have only gotten worse over the last five years. But the truth is I had to go to the bottom to rebuild my way back up. I am just surfacing.

ZZZ I SHOULD DIE: I have had an eating disorder for as long as I can remember. I do not remember life without it. I no long want this pain. I am afraid to overcome it for a few reasons. 1) I am afraid to because of the insecurity that I will have; and, 2) I do not want to gain weight (one of my biggest fears).

barbaras: I am 51, raised in an alcoholic and sexually abusive home. I was abducted at the age of 5 by a stranger and raped among other things. I want to quit throwing up, and I have gone as long as 3 weeks, but I always go to another destructive behavior and then back to throwing up and laxatives. I am so tired of fighting this. Is there any hope for recovery?

Aroma: Does Dr. Garner think that nutritional advice is a part of the psychotherapeutic process?

Dr. Garner: Yes. I do think nutritional advice can be helpful. On the subject of relapsing and when to return to treatment: People with eating disorders should have a low threshold for returning to treatment. It is not uncommon for patients to believe that a return to treatment would be a humiliating or unacceptable admission of failure. Common beliefs that interfere with re-initiating therapy are: "I should be able to do this on my own now; if I am having problems again, it means recovery is hopeless; the therapist will be disappointed or angry". Since patients commonly delay the reinitiating of treatment too long, a conservative approach is a good policy. If patients are not sure whether they should return for a follow-up consultation, this means that they should. Sometimes therapists need to define their role as a "family doctor" for eating disorders. Regular "check-ups" are prudent, and meetings at the earliest sign of relapse are the best protection against escalation of symptoms. Remain alert to warning signs of relapse: It is useful to review early signs of relapse with particular attention to weight or shape preoccupation, binge eating, precipitous weight gain, gradual or rapid weight loss and loss of menstrual periods. Patients need to ask themselves periodically: "Am I thinking too much about weight?" Sometimes weight loss occurs for other reasons such as depression or illness.

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HelenSMH: I was wondering, I received treatment called ECT (Electro Convulsive Therapy) for major depression. I don't think it had any effect on my eating disorder, but other inpatient people were getting ECT also for their eating disorder. I was wondering should/can ECT help with eating disorders?

Dr. Garner: ECT is absolutely contraindicated for eating disorders from my reading of the literature.

Suszy: I was wondering why it seems like I'm losing all of my friends over my eating disorder. I'm not hurting anyone but myself?

Dr. Garner: An eating disorder interferes with the ability to maintain social relationships for many reasons. However, unless you have a blueprint for recovery- unless you know how to proceed with recovery, you should not blame yourself for driving others away.

Bob M: Suszy's question brings up another issue: how does one explain their eating disorder to a friend or family member without alienating them?

Dr. Garner: An eating disorder is a problem. Problems can be solved. If it is presented as a solvable problem, rather than an illness, it should help to avoid alienating friends or family members.

Suebee: I recently read that one should not try to lose weight while attempting to recover from bulimia. Is this true?

Dr. Garner: ABSOLUTELY. THIS IS THE KEY!!!!!!

Penny33: Can experiences with bulimia affect bearing children, after a long time of recovery? Also, what areas of your body are affected harshly?

Dr. Garner: As long as recovery is complete, there does not seem to be a problem with bearing children. The long-term effects are unclear. For anorexia, bone loss is a big problem and dental problems can be severe with those who B/V.

clk: What are the side effects of long-term diet pill and laxative abuse and how does an inpatient stay help to gain control over this?

Dr. Garner: Those with eating disorders should be aware of the serious physical complications associated with starvation, self-induced vomiting and purgative abuse. These include electrolyte disturbances, general fatigue, muscle weakness, cramping, edema, constipation, cardiac arrhythmias, paresthesia, kidney disturbances, swollen salivary glands, dental deterioration, finger clubbing, edema, dehydration, bone demineralization, and cerebral atrophy. Laxative abuse is dangerous because it contributes to electrolyte imbalance and other physical complications. Perhaps the most compelling argument for discontinuing their use is that they are an ineffective method of trying to prevent the absorption of calories. An inpatient stay can be helpful in getting you off the laxatives if it is not possible as an outpatient.

Bob M: How common is it for a person to go from anorexia to bulimia or vice versa? And how does having the combination of both affect the chances of a successful recovery?

Dr. Garner: It is very common to move from anorexia to bulimia and less common, but it still occurs, for patients to move the other way. However, the important thing to remember is that the basic issues are similar, a fear of weight gain. Having anorexia and bulimia at the same time is now technically impossible because of the way the diagnositic criteria are worded. However, having anorexia and b/v does not confer a terrible prognosis- the underlying eating disorder is similar regardless of the weight.

hero: What is the treatment used for the compulsive overeater? I have lost and gained my entire life and I'm so tired of a life revolving around food. Can treatment happen without medication?

Dr. Garner: The treatment of choice is 1) not dieting (i.e. 3 meals spaced throughout the day, 2) no less than 2000 calories, and 3) eating former "binge foods" as part of your regular diet. Medication should best be used as an adjucnt to the cognitive behavioral treatments that now have received a great deal of empirical (research testing) support. If you do as I have indicated here, you will NOT continue to gain and will lose weight for the remainder of your life.

Alisonab: When you talked about the weight issue and how we still have a "goal weight"-- well what if we are in a bad medical situation and need to get out of this cycle, but because of the weight issue we cannot. Is there any other way around the weight issue?

Dr. Garner: Almost every bad medical condition is made worse by cycling up and down. I think that the best thing is to aim to stabilize your weight and look for other methods to improve your medical condition.

jbandlow: I've read recently that when an anorexic ingests food, there's a resulting decrease in some brain chemical that can actually cause one to feel worse about having eaten. Is this true? If so, can it be counteracted?

Dr. Garner: I do not think that it is quite this simple. Most anorexia patients feel terrible when they ingest food and this has more to do with feelings about eating and weight gain and loss of control than neurotransmitters. However, we still are in our infancy in our understanding of the effects of eating on brain chemistry.

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luvsmycats: Hi - how do you feel about keeping food diaries?

Dr. Garner: I think that it can be very helpful and meal planning can be even better for those who are really frightened of eating.

JazzyBelle: Why do people sometimes go to cutting themselves if they have an eating disorder?

Bob M: We are talking about self-injury here. And it seems that for some, eating disorders and self-injury go hand-in-hand.

Dr. Garner: Self injury occurs in about 15% of eating disordered patients. There are several reasons. 1) to increase pain to wipe out other feelings. 2) to increase sensations in those who are having trouble experiencing feelings, 3) to control others, since it elicits such strong reactions, and the person does not feel that she has any other way to achieve control.

Bob M: I'm not familiar with this part of the research, but are people genetically predisposed to having an eating disorder and/or does it seem to "run" in families? So, if I have an eating disorder, do I have to worry about my children having one?

Dr. Garner: There is evidence that eating disorders run in families. For example, anorexia occurs in 10% of sisters and fraternal twins, but 50% of identical twins. Moreover, children of those with eating disorders have a greater chance of developing eating disorders, but is this related to genes or to teaching the child things that make an eating disorder more likely? This remains unknown.

Bob M: We haven't touched on this part either yet...what about men with eating disorders. Do they face different issues when it comes to recovery? And is it any harder/easier for men to recover and do they suffer more/fewer relapses? Why?

Dr. Garner: Men face different issues since eating disorders are often thought of as "women's disorders" which can make it more difficult for men to seek treatment for their eating disorder. Also, there has been research suggesting that sexual identity conflict issues are more common among men with eating disorders. Arnold Andersen at the University of Iowa has done a great deal of research on this topic. It does not appear that men are less likely to recover. I just want to say before I sign off that, after working with people with eating disorders for years, I am really optimistic about the prospects for recovery. Every patient should know that recovery is possible, even after many years of serious illness.

Charlene: What can one do when not actively engaging in eating disordered behavior, but you are still constantly bothered by the thoughts? Is there anything besides costly therapy?

Dr. Garner: We have had two patients in our program recently who have had an eating disorder for 20 years and have made extraordinary progress in recovery. Not everyone makes this type of progress, but then, these patients who have made progress did not know they were going to do well until after participating in treatment. Thus, I encourage everyone to keep trying and to keep the faith in the possibility of recovery and a life without an eating disorder. I want to thank Bob and Concerned Counseling for providing this opportunity to discuss recovery- Now to Charlene:

If the thoughts are really intrusive, then I think that continued treatment would be helpful. Consult your Dr. for an opinion and recommendation. One assessment should not be that costly. I would not underestimate the pain caused by thoughts and they may very well warrant treatment. Best wishes, Dr. Garner.

Bob M: We had over 150 people coming in and out of the conference and I know we didn't get to everyone's questions. I want to thank Dr. Garner for being here this evening and for sharing his knowledge and information with us. And thank you to everyone in the audience who came tonight. I hope everyone has a good rest of the week. We have many people with eating disorders, all three, anorexia, bulimia, compulsive overeating who visit our site everyday. So if you are needing or wanting to give support, please stop in.

Dr. Garner: Good night and thanks Bob for providing me with this opportunity.

Bob M: Good Night everyone.

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