Eating disorders through developmental, not mental, lens | Richard Kreipe | TEDxBinghamtonUniversity

Summary

This script explores the multifaceted nature of anorexia nervosa through a developmental lens, challenging the traditional view of it as solely a mental illness. The speaker, with 40 years of experience, emphasizes the importance of understanding the adolescent developmental tasks intertwined with the disorder. By considering factors like puberty, identity formation, autonomy, and brain development, the narrative offers a more empathetic and holistic approach to treatment, suggesting that recognizing anorexia as a complex developmental issue can lead to better patient outcomes and less stigma.

Takeaways

• 🧠 The speaker emphasizes the importance of understanding anorexia nervosa from a developmental perspective rather than solely as a mental illness.
• 👩‍⚕️ The speaker's approach to treating anorexia nervosa involves listening to patients and not assuming they are manipulative or deceptive, which contrasts with some traditional views in the medical field.
• 👧 The development of anorexia nervosa is intricately linked with the developmental tasks of adolescence, such as puberty, identity formation, and the pursuit of autonomy.
• 🔄 The speaker highlights how the traditional view of anorexia nervosa as a psychiatric illness can be limiting, suggesting a more holistic, biopsychosocial model for understanding and treating the disorder.
• 📈 The script discusses how the patient's perception of feeling fat despite being thin is a valid subjective experience that should be acknowledged in treatment.
• 🏥 The speaker recounts personal experiences from the 1970s that led to a shift in perspective on anorexia nervosa, moving away from viewing it as solely a psychiatric issue.
• 🌟 The presentation suggests that hope and a positive outlook are crucial components in the recovery process for patients with anorexia nervosa.
• 💡 The concept of 'fertile soil' is used to describe the combination of traits that might make an individual more susceptible to developing an eating disorder, such as perfectionism and risk avoidance.
• 🌱 The speaker believes that the seeds of recovery are within the patient and that the role of the medical professional is to nurture and support growth.
• 👨‍👧‍👦 The family dynamics and environment are considered important factors in the development of anorexia nervosa, moving away from blaming the family and towards a partnership in treatment.
• 🧠💭 The speaker notes the significant changes in brain development during adolescence that can influence the thought processes and behaviors associated with anorexia nervosa.

Q & A

What is the main focus of the speaker's presentation on anorexia nervosa?

The speaker aims to provide a different perspective on anorexia nervosa, emphasizing the importance of understanding it as a developmental issue linked to adolescence, rather than solely as a mental illness.

Why did the speaker initially struggle to understand anorexia nervosa during his medical training?

The speaker struggled because he had never heard the term 'anorexia nervosa' during his medical and pediatric training, and the first case he encountered was isolated and surrounded by misconceptions about the condition.

What misconceptions about anorexia nervosa did the speaker encounter early in his career?

The speaker encountered misconceptions such as the belief that patients with anorexia nervosa are manipulative and untrustworthy, and that their families, particularly the parents, are at the core of the disorder.

How did the speaker's approach to treating patients with anorexia nervosa evolve?

The speaker's approach evolved from one of skepticism and adherence to traditional psychiatric views to one of listening, believing, and forming therapeutic relationships with patients, valuing their subjective experiences.

What is the significance of the developmental tasks of adolescence in the context of anorexia nervosa?

The developmental tasks of adolescence, such as puberty, identity formation, and the development of autonomy, are significant because they are seen as intertwined with the development of anorexia nervosa, influencing its emergence and progression.

How does the speaker describe the relationship between anorexia nervosa and the patient's sense of control?

The speaker describes anorexia nervosa as a misguided attempt by the patient to exert control over one aspect of their life—weight—when they feel they have no control over other aspects, thus providing a false sense of autonomy.

What role does the speaker believe that trust plays in the therapeutic relationship with patients with anorexia nervosa?

The speaker believes that trust is crucial in forming a therapeutic relationship, and he chooses to believe his patients until he has reason not to, which contrasts with the traditional view that patients with anorexia nervosa are inherently untrustworthy.

What is the 'biopsychosocial model' mentioned by the speaker, and how does it relate to anorexia nervosa?

The biopsychosocial model is a framework that considers biological, psychological, and social factors in understanding health and illness. The speaker applies this model to anorexia nervosa, arguing that it should be viewed as a complex interplay of these factors during adolescence, rather than a simple mental illness.

How does the speaker address the issue of patients lying or manipulating in the context of anorexia nervosa?

The speaker acknowledges the issue but chooses to 'listen to what [patients] tell me, but trust and verify,' allowing for the possibility of dishonesty while still maintaining a therapeutic relationship.

What is the significance of the phrase 'fertile soil for anorexia nervosa' used by the speaker?

The phrase 'fertile soil for anorexia nervosa' signifies that certain personality traits and predispositions, such as perfectionism, risk avoidance, and anxiety, create a conducive environment for the development of anorexia nervosa.

What message does the speaker hope to convey to the audience about treating eating disorders?

The speaker hopes to convey that treating eating disorders should involve understanding the developmental, biological, and social aspects of the patient's life, rather than focusing solely on the mental illness aspect, which can lead to more effective and compassionate care.

Outlines

00:00

🌱 Introduction to Anorexia Nervosa

The speaker invites the audience to relax and clear their minds, setting the stage for a discussion on anorexia nervosa. They acknowledge that preconceived notions may influence perceptions of the disorder. The speaker aims to provide a fresh perspective over the next 15 minutes, emphasizing their 40 years of experience and the importance of understanding the developmental stages of adolescence in relation to anorexia. The narrative begins with the speaker's initial encounter with anorexia during medical training and their journey to comprehend the condition beyond the labels of a psychiatric illness.

05:02

🔍 Challenging Misconceptions

This paragraph delves into the speaker's early experiences and the prevailing misconceptions about anorexia nervosa during the 1970s. The speaker highlights the extreme behaviors associated with the disorder, such as caloric restriction and compulsive exercise, and the potential fatal outcomes. They also address the negative stereotypes about patients with eating disorders, including the idea that they are manipulative and untrustworthy. The speaker challenges these views by advocating for a more empathetic and trusting approach, which is crucial for establishing a therapeutic relationship.

10:03

🌟 The Developmental Roots of Anorexia

The speaker explores the developmental factors that intertwine with the emergence of anorexia nervosa during adolescence. They discuss the impact of puberty, identity formation, and autonomy development on the condition. The speaker uses a drawing by a patient to illustrate the internal struggle between the desire to appear strong and the feeling of emptiness. The paragraph underscores the importance of considering the adolescent's developmental stage and the biological changes that occur during this period in understanding anorexia nervosa.

15:05

💭 The Role of Thinking in Anorexia

In this paragraph, the speaker examines the cognitive aspects of anorexia nervosa, particularly how the condition is linked to the logical yet flawed belief that controlling one's weight is the only way to exert control over life. They discuss the neuroscientific findings related to brain development during adolescence and how these changes can influence the thought processes of individuals with anorexia. The speaker emphasizes the importance of addressing the false conclusions that patients draw and the role of proper nutrition in cognitive recovery.

🌼 Embracing a Biopsychosocial Approach

The final paragraph concludes the speaker's presentation by advocating for a biopsychosocial model in understanding and treating anorexia nervosa. They argue against viewing the disorder solely as a mental illness and instead propose considering it within the context of an individual's developmental process. The speaker encourages a holistic approach that takes into account the influence of puberty, identity, autonomy, and cognitive development. They share a personal anecdote about a patient, highlighting the importance of a positive and supportive therapeutic relationship.

Keywords

💡Anorexia Nervosa

Anorexia Nervosa is an eating disorder characterized by an intense fear of gaining weight, a distorted body image, and severe food restriction. In the video, this term is central as it discusses the speaker's experiences and insights gained over 40 years in treating this condition, emphasizing the importance of understanding the patient's perspective and the developmental factors that contribute to its development.

💡Adolescence

Adolescence refers to the transitional stage between childhood and adulthood, typically occurring between the ages of 10 to 20. The video highlights how the developmental tasks of adolescence, such as puberty, identity formation, and autonomy, are closely linked to the development of anorexia nervosa, suggesting that this period is a critical time for intervention and understanding the disorder.

💡Puberty

Puberty is the process of physical changes through which a child's body matures into an adult body. The script discusses the role of puberty as a foundational factor in the development of anorexia nervosa, noting that sex hormones can influence genetic or environmental factors related to the disorder.

💡Identity

Identity in the context of the video refers to the development of a stable sense of self during adolescence. The script uses the term to describe how individuals with anorexia nervosa may struggle with identity formation, often feeling a disconnect between their external image and internal sense of self, as illustrated by the patient's self-portrait of feeling like an 'empty shell.'

💡Autonomy

Autonomy is the capacity to make an informed, uncoerced decision. The video script discusses how adolescents with anorexia nervosa may perceive controlling their food intake as a means to achieve a sense of autonomy and control over their lives, which they might otherwise feel is lacking.

💡Biopsychosocial Model

The biopsychosocial model is a framework that considers biological, psychological, and social factors in understanding human health and disease. The speaker advocates for this model in treating eating disorders, emphasizing the importance of considering the patient's environment and subjective experiences alongside objective medical findings.

💡Developmental Tasks

Developmental tasks are the skills, knowledge, and abilities that individuals are expected to acquire at certain stages of their life. The video script identifies several key developmental tasks of adolescence, such as puberty and identity formation, that are intertwined with the development of anorexia nervosa, suggesting that addressing these tasks is crucial for recovery.

💡Perfectionism

Perfectionism is a personality trait characterized by striving for flawlessness and setting excessively high standards for oneself. The script mentions perfectionism as a trait that can make an individual more susceptible to anorexia nervosa, as it can contribute to the rigid thinking and extreme behaviors associated with the disorder.

💡Manipulation

Manipulation refers to the act of influencing others in a cunning or deceitful way. The video discusses the misconception that individuals with eating disorders are inherently manipulative, challenging this stereotype by advocating for a more trusting and therapeutic relationship with patients.

💡Psychosomatic Family

The term psychosomatic family originates from the psychiatric literature and refers to a family dynamic where physical symptoms are believed to be influenced by psychological factors. The script critiques this concept, suggesting that it unfairly pathologizes family members and overlooks the patient's subjective experience.

💡Recovery

Recovery in the context of the video refers to the process of healing and regaining health after an illness or disorder. The speaker emphasizes the importance of a positive and supportive approach to recovery, highlighting the strengths within the patient and the potential for growth and change.

Highlights

Introduction to the concept of anorexia nervosa and its influence by personal and societal perceptions.

The speaker's initial lack of knowledge on anorexia nervosa and the evolution of understanding through patient interactions.

The importance of listening to patients' experiences without preconceived biases to foster a therapeutic relationship.

Anorexia nervosa being considered a mental illness with specific demographic and behavioral characteristics.

The historical view of patients with eating disorders as manipulative and untrustworthy, and its impact on treatment approaches.

The speaker's shift in perspective to view anorexia nervosa as a disruption of adolescent development rather than a cause.

The significance of puberty and its hormonal influences on the development of anorexia nervosa.

The role of identity formation during adolescence and its connection to anorexia nervosa.

A personal account from a patient illustrating the struggle with self-image and the desire for control through anorexia.

The developmental task of autonomy and its misalignment with the control exerted through anorexia nervosa.

Neuroscience insights on adolescent brain development and its relation to the logical yet flawed thinking in anorexia nervosa.

The speaker's approach to recovery, emphasizing the importance of nourishing the brain through proper nutrition.

A visual metaphor of hope and recovery presented through a patient's artwork.

The potential for a biopsychosocial model to offer a more comprehensive understanding and treatment of eating disorders.

The speaker's advocacy for a non-stigmatizing approach to treatment that considers the developmental aspects of anorexia nervosa.

The application of the biopsychosocial model to mental health in general, emphasizing the importance of personal narratives.

The speaker's personal anecdote about a patient's resilience and the role of the therapist as a facilitator of recovery.

The conclusion emphasizing the need for a developmental perspective in understanding and treating anorexia nervosa.

Transcripts

[Music]

I invite you to settle in and get

comfortable allowing your eyes to soften

their gaze and possibly even your

eyelids drift downward this will help

clear our minds of any debris and I

wonder what comes into your mind's eye

when I say the phrase anorexia nervosa

your image may be influenced by your own

personal experience with an eating

disorder or as a family member or loved

one or classmate or teammate or neighbor

or acquaintance of a person with an

eating disorder it may also be

influenced by your what you've learned

in school what you've heard from friends

or what you've seen on TV or social

media but over the next 15 minutes I

hope to provide a different perspective

of anorexia nervosa that gives us I

think a better way to address it as an

issue and how to help people recover

I'll start with presenting lessons I've

learned over the last 40 years by

listening to patients and parents and by

giving them hope and the region of a

future that can be healthy but what I'll

also do is focus on how the

developmental tasks a human development

from age 10 to 20 commonly called

adolescence is inexorably linked to the

development of anorexia nervosa and so I

hope that at the end of this there is an

idea that's worth spreading

so back in the 1970s when I started my

medical training I had never heard the

word in eight years of medical and

pediatric training never heard the word

anorexia nervosa and so two weeks before

I went to Rochester to start my

adolescent medicine fellowship I learned

about a patient with an erection of OSA

was admitted to the hospital

intrigued I went up to visit her but and

she was in a single room and the door

was closed and as I approached the room

I was told oh you can't go in there

nobody's allowed in there except her

psychiatrist and the got guests or

neurologists and I kind of stepped back

and said well is she contagious I mean

we was in a single room usually reserved

for isolation for infectious isolation

and I was told no no no no she has a

psychiatric illness and I said well why

is she on the GI Service if she has a

psychiatric illness well she feels for

when she eats a small amount of food so

I was really kind of struggling with

that it didn't make any sense to me but

I said okay I don't I don't understand

this and I don't need to I'll just

forget about it until two weeks later

when I start my fellowship in adolescent

medicine in Rochester and my very first

patient is a 15 year old girl named Liz

who was eerily similar in her story to

the person I was not allowed to talk to

in Philadelphia and now she's my patient

my mind's eye was a blank slate my mind

an empty vessel I had no clue what to do

and I think in that case made me a

little bit more open to what patients

actually had to tell me so I asked Liz

this doesn't make sense to me can you

help me understand how you can feel fat

when you are thin and I very much

intentionally avoided asking her to

justify having an eating disorder I said

it is possible for you to feel fat and

for me to think you're too thin but it

just doesn't make sense so as we talked

about it she helped me understand where

she was coming from it had to do with

her sense of control her sense of

identity the issue of going going up

through puberty etc and so I said so

what I hear you say is that you feel fat

true and based on my physical

examination your body is telling me it's

too thin true

it's not that you're right and I'm wrong

or I'm right and you're wrong we're both

right and between my hands it's where

your anorexia nervosa lives now being an

academic medicine fellow in Rochester I

learned from books I read books I

learned from articles and teachers that

anorexia nervosa was considered a mental

illness with up to 85 percent of

patients affected being girls 10 to 4 10

to 20 years of age and I learned that

they had extreme restriction of caloric

intake an extreme amount of compulsive

exercise all intended to either minimize

weight gain or maximized weight loss and

it did have a definite level of fatality

they could die from this

I was also warned that you know these

patients they will lie to you

they manipulate you you can't trust them

and parents were so much at the core of

the eating disorder that the term

keratectomy literally removal of the

parents from treatment was considered a

treatment option as if the parents were

a malignant growth and this was he fuel

to even more by the psychiatric

literature in the concept called the

psychosomatic family and in the

psychosomatic family the teenage

generally girl was labeled as spoiled

and manipulative the mother was put down

as smothering and emotionally

over-involved the father was withdrawn

or absent and the family dynamics were

interesting and that the individuals

developed the identities very poorly and

because there's poor identity formation

the boundaries between individuals were

crossed or blurred or non-existent and

then family dynamics in this mess were

described as enmeshed and conflict

avoidant and triangulated in power

struggles and unhealthy alliances and I

think the word that kind of pulls this

all together was a sentence that I

in an academic journal written by a

child nellessen psychiatrist who was

very well known at the time who wrote

the referral of a patient with an eating

disorder to a colleague is not viewed as

a friendly act so as a pediatrician and

adolescent medicine specialist I sense

that wait a minute maybe it's not the

cause maybe what I'm seeing is not the

cause maybe it's the result of having an

eating disorder disrupting adolescent

development and family life so I chose

to listen to patients and believed them

until I had reason not to and I was

again told wait a minute you have to

watch out these people lie manipulate

etc but how can i establish a

relationship with a patient that's

therapeutic when I assume that I can't

trust them when I have to feel that by

their very nature they're going to lie

to me in order to not gain weight well

if you can't form a therapeutic

relationship with a patient well why are

you doing what you're doing

so I naively kind of just said okay I'll

listen to what you what you tell me

but trust and verify and I had a friend

colleague who is a therapist for adults

who reminded me of an experience that he

had he visited a patient in a

psychiatric inpatient unit

he was an outpatient therapist and she

said you know nobody here trust me they

call me devious they call me

manipulative they don't believe a word I

say but you're different when I tell you

something you believe me and we very

calmly said I reserve the right to

believe you even when you lie to me

for me that was a seismic shift in

attitude from my previous schooling and

so coming to Rochester to study the

biopsychosocial model which talks about

adolescents and parents in concert

there's a the environment that the

person grows up in is important and so

that actually the patients

and parents subjective experience is

considered just as important as the

objective experience that I have from my

physical examination and history so it's

not one or the other it's we work

together we provide a partnership and so

now what I'd like to do is kind of look

at the developmental factors that I

think are embedded in adolescent

development but also embed in anorexia

nervosa

so the first developmental task is

puberty so between 10 and 20 years of

age the vast majority of individuals go

through puberty girl to woman boy to man

and that is a permanent transformative

change you're a different person after

you go through puberty and there's now

research that shows that sex hormones

depending on where they occur in the

source of in the course of pubertal

development have a modulating a factor

modulating the effect on factors known

to be effect either genetic or

environmental factors so puberty is an

important part of the development of

anorexia nervosa it kind of forms the

foundation for the emergence and

progression identity that's the second

major task of adolescence I know when I

was studying adolescent development I

learned about Erik Erikson's theory of

human development and in adolescent

phase it was you either came with a

stable sense of self or you had role

confusion or role diffusion well this is

a drawing by Sheree a 15 year old

patient who she had - drew a had to make

a drawing for show-and-tell at school

and this is her self-portrait pretty

striking and she said I need to feel

like I'm on superwoman on the outside

but inside I feel like an empty shell

and I asked her why she was kind of from

the head down to the torso her right and

left shifted from superwoman to skeletal

self and she said because my sense of

self is always changing but her sense of

self was also determined by

the food that she was eating there was

no fat no me the fork is overturned

she's clearly done with her meal just

beyond arm's reach are the forbidden

foods of cookie cakes by candy ice cream

the clock on the wall

always reads dinner time and the shelf

on the wall has jump rope for exercise

and diet books all focused on the

identity of thinness the third

developmental task is the development of

autonomy I think for many adolescents I

know when I was an adolescent autonomy

was really the main thing that I was

shooting for how to have a sense of

control people can't tell me what to do

and when we think about autonomy

development and and how adolescents have

to kind of gain their autonomy we can

talk about things like graduated curfews

or graduated driver's licenses or

restricted access to things like voting

or smoking or alcohol all of which are

seen as a restriction of an adolescent

autonomy but the problem with people

with anorexia nervosa is they don't have

a sense of control in their life they

don't have a sense of autonomy and so

it's a strange thing because where some

adolescents might gain a sense of

autonomy sense of control by sex drugs

and rock and roll these patients don't

have that option available to them so in

a strange way limiting your caloric

intake being defined by what's on this

what the scale says you are and and the

number of calories that you eat actually

makes sense especially if you're talking

about an individual who has fairly rigid

thinking and it's perfectionistic also

risk avoidant and harm aversive those

are all phrases that are used in

describing patients with anorexia

nervosa but when you think about it if

that's what you're struck by if that's

what you're limited by not having a

sense of control and actually

determining what you eat what goes into

your mouth actually is an ultimate sense

of autonomy and then there's also the

issue of thinking

so we now know from neuroscience that

the tremendous changes that happened

between 10 and 25 years of age in brain

development are due to connections being

made and lost and different kinds of

circuits being established and

especially with respect to the thinking

in anorexia nervosa what the patient is

what the individual with an erection of

OSA does it's very I'd like to point out

the patient's it's very very very

logical if you believe that you have no

control in your life other than your

weight

well I'll control my weight that will

give me a sense of control so the

problem is not that it's illogical the

problem is that it's very logical but

they start with a false conclusion the

only thing I can control is my weight so

when I'm working with patients I say

well first of all you're thinking get

screwy when you don't eat very well so I

really focus on food and feeding the

brain as a way of beginning recovery and

so I'd like to leave you with a image

this was a ceiling tile I asked patients

to draw something to leave for the next

patient with the ceiling with a with a

message of hope and I see some people

craning their heads try to look at it

upright and what it says is where hope

grows miracles blossom and I'm looking

at this upside down when I'm getting

ready to go to the patient's room who

drew this and I say oh well it's

interesting you know there's an aster

and maybe some daffodils and some roses

and different kinds of things that looks

pretty good but after I went in to talk

to her I came out and here was the

images I saw as its on its head and I

wonder how many people saw what you

might see now especially if you consider

in the middle the aster is a mouth and

two of the leaves are an eye and an

eyebrow and I hope that my short

presentation today helps you to realize

that when we consider things a mint when

we consider anorexia nervosa a mental

illness

we very much restrict and limit the

possibility of use

a developmental framework in a

biopsychosocial model and so what I hope

to do is to have us all start to when

we're thinking about treating eating

disorders think about the influence of

puberty and the sexual maturation to a

woman and adult think about the various

issues in identity formation think about

the tumultuous ride on autonomy

development and also the thinking

changes that would continue on into the

twenty five twenty five years of age or

more and I think with this kind of an

approach where we are not talking about

something as a mental illness but as a

developmental process that what you're

doing actually makes perfect sense I

think we'll be able to have a much

better outcome with treating patients a

we can get them earlier in Pediatrics

and B I think there will also be less of

a blaming and shaming area and I try to

be positive with my patients and I had

one patient who was she had a lot of

anxiety a lot of depression a lot of

obsessive-compulsive traits

perfectionism that comes with the

territory and I said to her you know you

are fertile soil for anorexia nervosa

because you're a hard-working person who

has perfectionistic goals you really

want to do what's well you are risk

avoidant your harm avoidant you tend to

be a little bit anxious you worry about

things you tend to get depressed and I

said and for that reason you are fertile

soil on the eve for the illness or to

develop however I also think you have

many strengths that you will be able to

overcome the eating disorder that you

have now and so I said you know the

seeds of recovery are within you and

without dropping a beat she said to me

yeah and you're the fertilizer

I took that as a greatest compliment

thank you

so you really emphasize the importance

of understanding the whole person in

your work specifically with eating

disorders do you think that there are

similar benefits to be had by applying

the same approach to mental illness for

lack of a better term in general

absolutely

well the biopsychosocial model is very

interesting was established 40 years ago

in Rochester by a psychiatrist who what

was an internist and he said I can't

figure out how to help these people by

using an internal medicine model so the

biopsychosocial model is back and forth

it's all different levels and they

interact with each other it's highly

dynamic it's highly ecological and I

think we need to apply that to

everything so once you know someone's

story their personal story you know much

more about them than when you check off

boxes in a in a you know in a survey etc

so I really talk to patients and tell me

your story and I believe it helps me to

understand them and them to understand

me and I think it's easier to form a

partnership in that kind of situation

all right that's very important thank

you thank you

you