Eating disorders through developmental, not mental, lens | Richard Kreipe | TEDxBinghamtonUniversity
Summary
TLDRThis 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
🌱 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.
🔍 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.
🌟 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.
💭 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.
Mindmap
Keywords
💡Anorexia Nervosa
💡Adolescence
💡Puberty
💡Identity
💡Autonomy
💡Biopsychosocial Model
💡Developmental Tasks
💡Perfectionism
💡Manipulation
💡Psychosomatic Family
💡Recovery
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
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