Category: Anorexia

training in eating disorders.

5/8/2014

This is not good.

This article from The International Journal of Eating Disorders highlights the lack of systematic training in medical schools in the US to treat the psychiatric illness with the highest mortality rate.

From the abstract:

"Of the 637 responding pro- grams, 514 did not offer any scheduled or elective rotations for EDs. Of the 123 programs offering rotations, only 42 offered a formal, scheduled rotation".

So, if your clinician is not being trained as in Eating Disorders why would you expect them to be able to provide adequate treatment? I'm not sure the situation in Australia is much better.

I would love to hear from The Australian and New Zealand Academy of Eating Disorders and the National Eating Disorder Collaboration about what they are doing to change this situation.

Chris Basten & Chris Thornton will be running some more training and Supervision programs for later this year and throughout next year. Details to follow.

CT

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Facebook doesn't cause anorexia

29/7/2014

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Many parents wonder about the impact of social media, such as Facebook, on their children. One concern is the impact on their self esteem and body image. I have been asked “Does Facebook cause Eating Disorders?” Short answer: No. Longer answer, like a relationship status: It’s complicated.

Researchers from Miami have just published an article in the International Journal of Eating Disorders that begins to highlight the complexities of the interaction between social media, body dissatisfaction, self esteem, and disordered eating.

Some previous studies have found a correlation (not causation) between greater Facebook use and disordered eating and higher levels of weight and shape concerns when compared to users of other internet activities. Posting photos and viewing photo’s is correlated to body image disturbance and an increase rate of body comparision. Importatly, these studies are correlational (those who are high in body comparison and body dissatisfaction may be more likely to look at photos) and do not tell us what might lead to what.

One longitudinal study looked at college women’s tendency to seek out negative feedback and engage in social comparisons predicted bulimic and overeating symptoms at a later date. It was postulated that Facebook use led to body dissatisfaction which led to disordered symptoms.

The Miami study took 185 College students with an average age of 18. Individuals in this study who reported a greater “negative feedback seeking style” were more likely to report an increase in their dietary restraint in their eating a month later if they received a larger number of Facebook comments. However, the "negative feedback seeking style" was measured by only one question “(I sometimes write negative things about myself in my status updates to see if others respond with negative comments about me)". Also the increase in restraint was correlated with the number of comments, some of which would have been positive and reassuring.

Individuals were more likely to report higher shape, weight and eating concerns when they received negative comments in response to personally revealing Facebook comments.

So, posting negative comments about yourself on Facebook, and receiving comments about your post (either negative or positive) did tend to increase restraint in this study, as it has in some other studies. I am not sure in would increase restraint or eating disordered attitudes more than magazines and other media images do. There is a strong body of literature indicating that these sorts of images do increase body dissatisfaction, which increases dieting which is, in turn, a risk factor for eating disorders (particularly bulimia nervosa).

As always comments and thoughts are welcome either on our Facebook page or on the Website below.

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The model or the CLINICIAN: Who comes first?

18/11/2013

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Last week I was asked by the Australian and New Zealand Academy of eating Disorders and by the National Eating Disorders Collaboration lead a discussion on what are the core competencies for someone working in the field of eating disoders. As part of that I gave a presentation entitiled "The Model or The Clinician - Who comes first?" I have attached a link to a PDF of the slides here.

I thought I might just provide some context for some of the slides so it makes some sense.

We start with a brief review of the evidence base in the eating disorders (along with one of my favourite quotes from Christopher Hitchens "What can be asserted without evidence can also be dismissed without evidence".

Slide 3 reminds us we do have Clinical Practice Guidelines to direct us, as well as a more recent Cochrane review and also (slide 4) great review by Bulik (up to 2005) and then Hay (2005-20013). Both published in International Journal of Eating Disorders.

Slide 5 suggests there is the strongest evidence for FBT in the treatment of adolescents with anorexia nervosa, but Slide 6 reminds us that that data (for full recovery - which is the standard to which I hold myself) indicates full remission for 50% of patients. (i.e. it's good but 50% ain't great).

Slide 7 & 8 makes similar point for CBT for BN. Good data suggesting good outcome for most, but again about 50% of patients remain symptomatic at end of treatment. There are also other treatments that are helpful for BN and BED, such as Interpersonal Therapy or DBT. The weight of evidence suggests however a first line treatment for BN should be CBT.

Slide 9 covers adult AN, where our results are poor. Most treatments get about 20% of patients to full remission, and get a substantially higher number to partial remission. 10,11, 12 summarise the latest study from Germany - the ANTOP study. This study again found that the type of treatment (a manualised psychotherapy or CBTE) didn't really matter in terms of outcome. Our treatment manuals aren't guiding us to what we should specifically do with adult patients in AN. I would point out however that the majority of the manuals focus on improving nutrition.

So we have some data to guide us on what may be helpful in the treatment of eating disorders. However, the question is how many practitioners are using the evidence base which suggests some empirically supported treatments exist.

Slide 15 was chosen not because the Tobin study is the best one indicating the Research Practice Gap, but because it has the coolest name (I know what you did last summer ... and it wasn't CBT) and it allowed me to put up a poster of SMG. There is a concerning "What Manual" with 21% of clinicians asked do they use a manual in the treatment of BN. I am more interested in the "flexible" user group, as this is where manual and clinician come together (maybe).

16 is on who uses manuals. Well when I here CBT, research focused and young I tend to think of my Doctor of Clinical Psychology and Master of Clinical Psychology students (some of who are pictured in the slide). When the first graduate the don't have the clinical experience, so should be sticking close to the manualised treatment where ever possible.

17 is some of the reasons people don't use manuals. I am most worried about those who don't know the manual. Slide 18 is an interesting study that indicated that even of those for whom CBT was their treatment of choice, few had formally being trained in the manual. ANZAED and the various state based training organisations must roll out training in evidence based treatment. I know Victoria have done this with FBT, as has NZ, but NSW is far behind.

RCT's dont exclude most patients - its an excuse we use when our results aren't as good as RCT. I have never met an eating disordered clinician who doesn't think they have the toughest patients that have all been excluded from RCT. The evidence generally suggests that treatments do disseminate if you use them.

Maybe our treatment models are "ignorant". I am thinking here of adult anorexia nervosa. Maybe drive for thinness or drive for control just doesn't cut it. I look forward to looking at the data coming out of neuropsychiatry labs like Walter Kaye's and the emerging research on Cognitive Remediation Training that may increase the outcomes for CBT.

The most common reason proffered for not using the Empirically Supported Treatment is that therapy is an art that should not be restrained by a cookbook. Surprisingly I agree with this to some extent. Mainly in the restraints that an RCT puts on the length of treatment. Maybe 40 sessions is not enough for adult anorexia (see the ANTOP studies weight graph that shows people keep getting better after treatment). Sometimes patients may need 30 sessions of FBT rather than stopping at 20 as the manual and RCT protocols suggest.

However, there are ideas in the manuals that help our patients. Our therapies need to reflect this.

As clinicians we need to remember that Evidence Based Practice is a three legged stool. Yes, one leg is Empirically Supported Treatments (our manuals). The other legs are clinical experience and also patients values and preferences.
Each of our camps tend to grab onto on leg of the stool and pull. The stool then looks a bit like a "hitting stick" (Slide 20) to beat people over the head with. Or as Phillipa Hay once wrote in response to our article "tyrannise" people with THE EVIDENCE.

However, as clinicians we need to however be aware of our own humanity and vulnerability to thinking errors - most importantly the confirmation bias (slide 21). This is when we do what we think works and collect evidence that it works and discount evidence it doesn't. This bias can lead us to do things that don't work continually, because we assume they do. It is this that, in my opinion, using manuals grounded in science helps us with.

You know I'm using a boring quote when I use a picture of a cute baby to keep the audience interested. I prefer the quote (from the book "Mistakes were made .... but not by me - which btw is going on my tombstone) about science being 'arrogance control'. Clinicians, and unfortunately I can't exclude myself here, can be some of the most arrogant people I now. We think we know that what we do is right and, if unchecked, our confirmation bias keeps it going.

Im not just bashing clinicians who wont use the evidence base. We need to be aware that as science evolves the evidence base will keep changing and we need to be ready to integrate new evidence into our formulations. For example the evidence for the cognitive behavioural model of BN is not as strong as I thought. I had selectively neglected a body of literature that indicates that dietary restraint may not lead to binge eating - although my clinical experience tells me it does. We all need to keep changing and adapting.

So, Im not bashing flexible manual users (which surprised some in the audience). Indeed I think I am one. The manual keeps me "anchored" to principles that are helpful. I try to integrate the concepts in the manual using my clinical experience - sometimes this is not the order the manual tells me. As clinicians we need to be aware of our tendency to drift into the latest clinical 'fad' or basing out therapy on the latest book we have read or workshop we have attended unless they have data to support them (ACT show me your data please).

Slides 24 & 25 are about the idea that maybe what we do is better than the manualised treatment. I feel all practitioners need to be accountable and to measure (and publish) their outcomes - this is the cornerstone of the generation of Practice Based Evidence. Be able to show what you do works. If it does - teach me what you do (make it disseminate-able).

We finish with the photo's of me cooking a BBQ, Jamie Oliver and Heston Blumenthal. I suggest manuals are a bit like cookbooks (which some take as a criticism). I can't cook. For me to cook chicken pizza - you need to give me a McCain's frozen Pizza that has all the ingredients included with strict instructions on what to do (including remove the plastic, turn on the oven to 180 degrees, place on a tray in the oven, leave in for 25 mins etc. Detailed step by step instructions. Heston may prepare a chicken pizza for you. It wont have chicken, pizza base and may be served as a gas - it is art, but it is not chicken pizza. Jamie however, has some instructions for chicken pizza, He includes a chicken and a pizza base. He can add to that base whatever he likes that might make it better. He doesn't need to be told when to remove the pizza from the oven - he just knows (he could tell you when to though). He uses the key ingredients in an understandable manner. He adds to the recipe in a way as guided by his experience, but his chicken pizza can be replicated by those who want to. When it comes to the treatment of our patients, I think Jamie serves as a model that integrates clinician and model.

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Mind and its potential presentation.

16/2/2013

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In 2012 I was privileged to present at the Mind and its Potential Conference. Below is the video of my presentation. It has been on our Facebook page for a while and got shared around the viral world with really good feedback for which I am grateful. I thought I should put it up on our webpage.

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"Denial" in Anorexia: Wilful or Choiceless (or in between)

25/5/2012

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The “denial” (note those “”) of the illness in anorexia is well described. It is one of the most frustrating aspects of the illness for carers and clinicians alike. It contributes greatly to the expressed emotion (frustration, anger, criticism and patient blaming) that comes from clinicians and acts as a therapist driven therapy interfering behaviour. Therapist will describe their feelings that somehow the patient is willfully lying to them, because the patient “must” be aware of their illness. They are being that naughty anorexic patient who seems to seek out to disrupt therapy.

What if clinicians ask that question that we ask patients so often “Is there a different, more workable, way of thinking about this?” As always, the answer is yes.

Until I began reading the blogs of Laura Collins, I had never heard of anosognisia. This is apparently a common problem in several brain diseases which where the sufferer no insight or is unaware of the illness. It occurs in neurological diseases such as Alzheimer’s disease, Huntington’s disease and after strokes. It can also be a feature of schizophrenia and bipolar disorder.

Some FMRI pictures and more information can be found here.

Im not sure if it has ever been studied in anorexia nervosa. Im not sure if it would be preexisting and exacerbated by starvation, or caused by starvation.

It important though for us to hold information in a way that may help us see that anorexia nervosa is not a willful choice. Holding this stance is incredibly helpful for therapist (and hence their patients).

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Is Maudsley Family Based Therapy the right treatment for you?

16/2/2012

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By Chris Thornton - Clinical Director of The Redleaf Practice
and Dr. Stuart Murray - Director of Family Therapy at The Redleaf Practice
The learned doctor says to the family of the young girl suffering from anorexia nervosa, "I'm not sure if Maudsley is the right treatment for you. I think individual therapy would be much better for you".

There may be many reasons that said learned doctor may say this to this patients family. Some of the most common ones will be; “we know that Maudsley doesn't work for everyone (and you are one of those)”; “you/your daughter is too old or to psychologically mature”; “anorexia is a chronic illness and is resistant to treatment so it is not logical that a family could renourish a starving child in the long term ( as hospital has often failed to do)”; “your daughter is not motivated to change”; “your daughter's eating disorder is too severe to be treated with family therapy”; “your daughter needs to be helped to separate for you and learn to make her own decisions”; and the less often expressed but implied - “your daughter has an eating disorder which means you have caused it by over enmeshment with your child; as it was your fault you can not be involved in fixing it.”

I'm sure that the learned doctor is not trying to practice in an uninformed or unethical way. They mean no malintent. It is just by behaving in an uninformed way, they are potentially depriving their patient of the leading treatment available for adolescents with anorexia. This is a potentially lethal mistake. In my humble opinion it is also unethical

“MFBT does not work for everyone”

Numerous reviews of the scientific literature have reported six Randomised Control Trials involving MFBT. These have indicated the clinical effectiveness of the treatment approach. The outcome data for this therapy is strong with around 70-80% of patients undertaking MFBT achieving a good recovery after 12 months and 90% recovery after 5 years (Lock et al. 2006).

Previously, one fair criticism was that MFBT had not been compared to an individual therapy that would be suitable for adolescents. This was rectified in 2010 when Lock et al (2010) published data that indicated that MFBT was superior to Adolescent Focused Therapy in terms of weight gain and change on the Eating Disorders Examination (a measure of eating disorder behaviour and cognitions) at end of treatment. MFBT was also superior in terms of full remission rates at both 6 and 12 month follow up.

That is between 70 - 90% of patients do well with MFBT, and MFBT seems superior to when the adolescent was treated in individual therapy. It is correct to say that MFBT won't work for everyone, it will however assist 70-90% of patients gets well. This compares favourably with the natural history of Anorexia Nervosa which shows a recovery rate of less than 50% at 5 years.

MFBT is, without question, the first line treatment of choice for an adolescent or child with anorexia nervosa. Any practitioner that recommends against it is giving you bad advice.

“MBFT will not work for your child because the Anorexia is too severe”

It is important to work out which families may do well with MFBT. We now have some data, based on one study, done by the originators of MFBT, that might help use science to answer some of the learned (but paradoxically, uninformed) doctors other criticisms.

The paper I'm looking at today is by Daniel le Grange et al (2112). This paper tries to break down the data and see if we can be guided in looking at which families MFBT may work best for. Previous studies have indicated that for greater weight change, patients with HIGH levels of eating related obsessionality did better with a longer, rather than a shorter course of MFBT. This makes sense as it is typically thought that the higher levels of obsessionality the more severe the patients anorexia. Single parent or non intact families also did better ( in terms of eating disorder psychopathology) with a shorter rather than longer course. This again makes sense as MFBT is difficult enough for "intact families" and single parent families are likely to need support over a longer period.

The most recent study found the following :

Again, patients with the MORE SEVERE ILLNESS DID BETTER WITH MFBT than AOT. Both patients with higher level of obsessionality and higher global EDE scores did better when treated with MFBT than in individual therapy at the end of treatment. In addition the presence of the binge-purge subtype of anorexia seemed also to do better at follow up when treated with FBT over individual therapy. This was not a significant result but is interesting because the presence of binge-purge behaviour is also an indication of the drivenness of the patient to lose weight (ie higher anorexic severity).

It did not matter as to how depressed you were, what your level of self esteem was, your level of self efficacy (of patient or parent), or BMI at beginning of treatment (although patients weights were above 75% of ideal body weight at the beginning of the study). There was no difference between treatment here.

This means that these variables, including markers of severity such as weight and depression, do not help us determine if MFBT or individual therapy would be better. MFBT should not be denied on these markers of “severity”.

Outcome in both treatment was worse if you had required an inpatient admission. Notably it did not mean that MFBT was less helpful if you had this marker of severity and is hence not a reason to note use MBFT as your first line treatment. Again in BOTH conditions older adolescents had a poorer level of remission of illness irrespective of the type of treatment. The same can be said for duration of illness. What these point to is the need for early and active treatment of the illness with the most effective treatment.

A common ‘learned Doctor” reason to not use MFBT is that the older adolescent, with their assumed greater maturity and insight may be more suitable to an individual approach (actually the studies authors of the current study predicted this). This data says that this is not the case. Age is not a factor in not choosing MFBT.

“You shouldn’t use MFBT because you can’t trust the research”

I have heard this said often as an argument to not use Evidence Based Treatments. It is tantamount to saying the data supporting MBFT is scientific fraud. Clinicians will often claim that the patients selected in the research studies are “not like my patients”. They usually sound very convincing, but I’m not sure how they know. What may not be openly discussed, is that in such cases the learned doctor may be (unintentionally) overlooking many years of international scientific and rigorous research, on the basis of an opinion with no scientific support. This advice may jeopardize your child’s well being.

The only way to work this out is to look at the exclusion criteria used in studies. In the study discussed above the exclusion criteria were: currently psychotic, dependent on drugs or alcohol, had diabetes or were pregnant, or had previously had MFBT or AFT. Patients were not excluded for common comorbid diagnosis such as anxiety, OCD, or depression. In my practice I would not engage in an active treatment for an eating disorder patients with psychosis or active substance issue. I would treat patients with diabetes and who are pregnant. Patients also had to be seen to be medically fit for outpatient treatment, which is entirely reasonable.

The patients in these studies are the same as the patients who present to an eating disorders clinic. There is no reason not to apply the scientific findings to your child.

“Individual therapy would be better for your child (... because it is your
fault she has it)”

If anyone can show me any data about an etiological role for families in anorexia I would be very happy to see it. Until then, I am going to keep putting it out there that families are not the cause of anorexia. To continue to hold this view restrains the treatment of anorexia. To the contrary, families are the single most effective resource in getting children well from anorexia.

To say that families cause or maintain anorexia is wholly uninformed. The presence of any life threatening illness naturally causes changes within family functioning, and anorexia is no different. Simply put, everybody in the family is effected by the presence of AN, and not just the patient. It can make some family members to feel guilty, others to feel angry, and it can often coerce us away from our normal instincts and relationships through fear of not wanting to elicit an anorexic backlash or exacerbate symptom severity. In a sense, the presence of anorexia, and the fear it sometimes elicits, can result in some families almost becoming used to the anorexic regime. To my mind, this a symptom of the anorexia which impacts the whole family, and does not mean that the family caused or is maintaining their child’s anorexia.

What strikes me is that it is impossible to address such family wide effects of anorexia in individual therapy. In my opinion, one of the reasons why MFBT is so effective is precisely that it relies on parental expertise. Nobody knows children better than their parents, nobody loves them more, and nobody will fight harder to save their life. Also, the changes brought about in MFBT (which include addressing the family wide symptoms) lead to lasting change because children live and exist in the context of their families 24/7. This is most certainly support by scientific research which shows that even after 5 years, 90% of children who undergo MFBT are still symptom free.

MFBT is most certainly a difficult form of treatment, and in many instances is one of the tougher challenges a family will face. However, this alone is not sufficient to dissuade people from commencing a treatment which although difficult, is highly effective in saving their child’s life. In my experience, every single family I have worked with has said during the course of treatment that the sacrifices and challenges involved in getting their child well pale into insignificance when considering the potential thought of their child not getting well.

“MFBT is only about weight gain and will not take into account the underlying psychological factors that have caused the anorexia”

Even if this was true, and MFBT was a only a vehicle for weight gain, this may not be a bad thing as weight gain and full nutrition is needed in recovery from anorexia. However, weight gain is necessary but not sufficient for recovery. Otherwise, hospitalisng patients and refeeding to normal weights would be curative. We know that it is not.

The idea that MFBT does not address adolescent issues that may be involved in maintaining the anorexia simply indicates that the maker of the statement does not have a rudimentary understanding of, and certainly no training in, MBFT. Phase 1 - agreed, it is focused on weight gain. Simply put, the magnitude of the potential medical crisis means that treatment is justifiably focused on weight gain, to reverse the features of starvation which trap many adolescents in long term anorexia. However, to achieve this weight gain there are usually some important changes that occur in the structure of families (such as everyone being present at meal times; health becoming a priority; sibling relationships are strengthened and parent relationships are empowered). Then in Phase 2 - eating is handed back to the adolescent and in Phase 3- adolescent issues are addressed. Repeat in phase 3 (and in practice it probably begins in phase 2) adolescent issues are addressed. It is just that these issues are addressed in an individual without a starved brain rather than prior to refeeding. I have done enough individual therapy with patients with a starved brain to recommend against it whenever possible.

Conclusion.

When we look at the data, there are very few reasons to suggest an individual approach over MFBT approach in the treatment of adolescent anorexia. MFBT needs to be the first line treatment as over 70% of families will have a good outcome with MFBT. Any advice to the contrary is, at best misguided, and is not based on the latest evidence. We do need some more information about extremely low weight patients, but overall, patients with high levels of severity do as well or better with MFBT. There does not seem to be any reason to not offer MBFT based on measures of “family dysfunction”. The initial goals of MFBT are weight gain, as they should be in the treatment of anorexia. The notion that MFBT is only about refeeding is misguided and shows a lack of training in MFBT. Lack of initial and ongoing training in Evidence Based Therapy in the eating disorders is a major problem which needs to be addressed as a priority.

with thanks to www.maudsleyparents.org

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The Futility of Fighting your Body.

29/12/2011

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I came across a Facebook page called leftoverstogo which in turn directed me to an article which was just published in The New York Times called “The Fat Trap”.

http://www.nytimes.com/2012/01/01/magazine/tara-parker-pope-fat-trap.html?pagewanted=all

The article itself is well worth reading, although there a more statistics in there than in many scientific articles I’ve read so it is not the easiest read.

It reminded me however of the enormous complexity of weight loss and how the body has been programmed to fights against it and defend a weight that is biologically predetermined. The article is written from the perspective of obesity, but applies to anorexia and bulimia as well.

The article discuses how we already know that efforts at weight control trigger metabolic and hormonal changes that work to defend a higher weight. However, newer research showed that...

“a full year after significant weight loss, these men and women remained in what could be described as a biologically altered state. Their still-plump bodies were acting as if they were starving and were working overtime to regain the pounds they lost. For instance, a gastric hormone called ghrelin, often dubbed the “hunger hormone,” was about 20 percent higher than at the start of the study. Another hormone associated with suppressing hunger, peptide YY, was also abnormally low. Levels of leptin, a hormone that suppresses hunger and increases metabolism, also remained lower than expected. A cocktail of other hormones associated with hunger and metabolism all remained significantly changed compared to pre-dieting levels. It was almost as if weight loss had put their bodies into a unique metabolic state, a sort of post-dieting syndrome..’

also ... “researchers have so far confirmed 32 distinct genetic variations associated with obesity or body-mass index”.

If this applies to obesity it also applies to anorexia (in particular given the evidence of genetic contribution to this illness) and also bulimia nervosa. This explains why those suffering from the eating disorders become so preoccupied with food weight and shape during the course of the illness. It is also why continued weight loss becomes harder and harder work with greater suffering leading to less “reward”.

The article describes neurobiological research helping us to understand the link between starving and binge eating.

“Another way that the body seems to fight weight loss is by altering the way the brain responds to food. Rosenbaum and his colleague Joy Hirsch, a neuroscientist also at Columbia, used functional magnetic resonance imaging to track the brain patterns of people before and after weight loss while they looked at objects like grapes, Gummi Bears, chocolate, broccoli, cellphones and yo-yos. After weight loss, when the dieter looked at food, the scans showed a bigger response in the parts of the brain associated with reward and a lower response in the areas associated with control. This suggests that the body, in order to get back to its pre-diet weight, induces cravings by making the person feel more excited about food and giving him or her less willpower to resist a high-calorie treat.

“After you’ve lost weight, your brain has a greater emotional response to food,” Rosenbaum says. “You want it more, but the areas of the brain involved in restraint are less active.”

The struggle against the body is one that is endless and rigged against you. The cost are enormous.

The article tells the story of one person who has successfully maintained her weight loss from obesity, which, as we know is a rare occurrence. Although the woman reports being happy with her daily routine it was hauntingly familiar.

“Janice Bridge, a registry member who has successfully maintained a 135-pound weight loss for about five years, is a perfect example. “It’s one of the hardest things there is,” she says. “It’s something that has to be focused on every minute. I’m not always thinking about food, but I am always aware of food.”

So she never lets up. Since October 2006 she has weighed herself every morning and recorded the result in a weight diary. She even carries a scale with her when she travels. In the past six years, she made only one exception to this routine: a two-week, no-weigh vacation in Hawaii.

She also weighs everything in the kitchen. She knows that lettuce is about 5 calories a cup, while flour is about 400. If she goes out to dinner, she conducts a Web search first to look at the menu and calculate calories to help her decide what to order. ... She writes down everything she eats. At night, she transfers all the information to an electronic record”.

To maintain a normal weight she needs to engage in many of the behaviours patients with eating disorders perform in the same ritualised way. This of course dosent mean that she has an eating disorder but I wonder if there are not more fulfilling things to focus on than measuring food and knowing how many calories you burn off during gardening.

I thought the article worth sharing as knowing about the futility of trying to fight the body may be helpful in evaluating the pro’s and con’s of continuing on in a fruitless battle.

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training in eating disorders.

Facebook doesn't cause anorexia

The model or the CLINICIAN: Who comes first?

Mind and its potential presentation.

"Denial" in Anorexia: Wilful or Choiceless (or in between)

Is Maudsley Family Based Therapy the right treatment for you?

The Futility of Fighting your Body.

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