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The message that needs promotion in our culture is that girls’ and women’s self-esteem cannot be connected to body and weight. If image and looks are the most important elements of a woman and if thinness continues to be glorified, then dieting will still be a rite of passage for adolescent girls and eating disorders will continue to be an intractable problem. 

Despite the sentiment that girls are capable of choosing any profession—that they can have it all—they continue to be burdened by anachronistic mores about appearance. The two cannot exist together without severe consequences. In fact, the drive for thinness only weakens the growth of a girl or woman because the energy consumed by dieting and weight detracts from attention needed to build a full life. 

By and large, men don’t have this problem. Some men do have eating disorders and body image issues that largely revolve around the fat phobia pervasive in our society, also a pressing and important issue. But they aren’t trapped behind sexist expectations that a woman prioritize image over everything else. 

The media has created an ideal for women in recent decades of extreme thinness and a photoshopped perfect body. In other words, not only is thinness a goal, but the objective is unattainable. The drive for thinness is inevitably a setup for failure. So the result of focusing on weight is shame and failure. And that is how a significant number of women experience themselves day in day out. 

There is a growing chorus of angry women’s voices expressing outrage about the shackles of thinness and weight. From the body positive movement to the concept of intuitive eating to the food coaching movement, younger people are listening to influencers who making a difference. These voices need to penetrate communities where dieting is a part of every 13 year old girl’s development and be sure the overwrought fears of obesity don’t scare people away.

These voices need to make clear the risks of spending a lifetime suffering in shame. These voices need to make clear that all body shapes are healthy and ok. These voices need to remind everyone what is truly valuable in life.
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These last two posts outlined some of the causes of body image distortion and how one’s mind can latch onto these self-images. The power of negative body image feels like a truth, a rite of passage passed down from mothers to daughters or within communities.

Because this component of eating disorders is a culturally accepted norm, changing the root of the distortion is exponentially more difficult. The outside world continues to state that thinness is a virtue, if not an accomplishment. Among women, telling one another “you look like you’ve lost weight” is still the ultimate compliment.

The task for the clinician of convincing a patient that the goal of thinness, a central part of society, is somehow false is a tall order. A therapist may be able to work against eating disorder thoughts that tell people to starve or binge and purge, but it’s a much more difficult goal to contradict the belief that women need to focus on weight loss as a sign of success.

This contradiction comes up in recovery very regularly. Even the most educated and supportive families struggle not to question their child’s meal plan and become afraid of too much weight gain. Even after years of watching their family member suffer with an eating disorder, the overall pressure for thinness can often override a person’s general health and wellness.

The drive for thinness leads to dieting, the most significant risk factor for developing an eating disorder, and also makes recovery more difficult because of the pressure not to gain weight, even if that’s necessary to get well. Trapped on both sides, people often feel most stuck because of body image distortion in their recovery. This is the last element of the illness that gets better.


Ultimately, body image distortion will only change when the cultural norm changes, something well beyond the lone clinician’s ability. This focus on weight remains a curse in our lives and especially women’s lives. Nothing will change unless the people most affected find a way to band together and insist on those changes. Life has to be more important than weight.
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The last post focused on the changes in brain processing which affect body image and the perception of one’s own body differently from others. Another equally important aspect of body image distortion is the emotional connection.

The underlying feeling behind body image thoughts is shame. Thoughts about body always revolve around never being enough: not thin enough, not shapely enough, not attractive enough. The list is endless.

Typically, these thoughts about one’s body starts around puberty when bodies change quickly and suddenly. The development of identity and self-perception occurs at the same time and often in lasting ways.

Adolescents, especially girls, still grow up with the message that their changing bodies are a source of deep shame. That shame may begin in how they are perceived with a developing body, how they dress, how they develop curves or fat in typical places for women or in the deep discomfort others, typically family, have during their development. Sometimes, the shame begins at home and other times from school or peers.

Because of the drive for thinness in our society, many children see dieting, food restriction and weight loss as a concrete way to battle against puberty and attempt to halt the changes in their body. The cultural norm of thinness naturally condones this dangerous behavior and assures teenagers that body shame is a critical part of becoming a woman.

As I have written many times in this blog, dieting is the number one risk factor for developing an eating disorder. Whether or not children become ill, for the most part, they learn about the connection between shame and body image. And the constant negative thoughts associated with their own self-image is quickly ingrained in so many girls and young women.


The new trends of body positivity, varied size models and body acceptance are taking hold. Both for the sake of avoiding eating disorders and for avoiding a lifetime of shame, let’s hope these trends make a dent in the cultural norms of the last fifty years.
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People with eating disorders struggle more with body image than with any other part of their illness. Even when eating behaviors have normalized, body image distortion often persists for years afterwards before fading.

The first component of body image thoughts manifests as a brain distortion. The visual image of one’s body is transformed in the brain into something very different from reality. At the most extreme, people who are very underweight see a much larger person on the mirror. Others may only see a body that disgusts them no matter its appearance.

As one’s own reflection is associated with such negative thoughts and feelings, it becomes impossible to disconnect the internal reaction from the way their body actually looks.

I have seen many people have an experience that highlights the power of body image distortions. These patients have told me that they will catch the reflection of their silhouette in a store window and not realize they are seeing themselves. In that moment, they describe having a positive feeling about that body and often a jealous reaction that they wish it was their body. Once they realize it actually is their body, the reaction immediately changes to seeing a body they hate which leads to disgust and hatred.

This moment makes clear how body image symptoms can be seen as a brain malfunction. The brain of someone with an eating disorder can process one’s own image very differently depending on the context. The exact same body can be a source of envy or the locus of disgust depending on whose body it is.


The connection of positive or negative feelings with one’s body grows from years of associations with how one feels about oneself. The core of the negative associations starts at a younger age and coalesces around body and body image through the process of childhood and into an eating disorder. The next post will focus on this process.
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As Bariatric surgery widens its reach in diet and weight loss culture, the psychological risks for many patients increase dramatically.

Originally, these surgeries were meant to be last ditch efforts for people with very high weight and clear and evident medical risks. When weight leads to organ failure and shortened life, it makes sense to consider drastic options. But these circumstances are very rare.

Acceding to the lure of financial gain and a completely new surgical speciality, doctors have increased the type of surgeries and the people eligible for them as well. It’s clear that medicine does not have a clear handle on the long-term anatomical and medical risks associated with these procedures. The siren call of permanent weight loss—without any factual basis to the long-term benefit of surgery—is enough to pull in a multitude of desperate patients.

What these surgical centers lack is a thorough psychological screening for their patients. Having performed several of them and reviewed many others, the centers expect a cursory screening at best. Surgeons and hospitals don’t want to know about latent eating disorders or even more obvious ones. They want to check the necessary boxes and perform more surgeries.

Our culture prays upon people unsure of themselves who have determined that they can manage their own personal limitations by losing weight. Since diets never work, people seek out more desperate measures as time goes on. One increasingly common decision is to research Bariatric surgery.


The surgeons don’t seem to realize they are exploiting cultural vulnerabilities for their own professional gain rather than helping people manage their own health and longevity. Bariatric surgery may have its place in very specific situations, but the overall message of a quick surgical fix to a cultural problem only reinforces the cynical nature of our diet culture.
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Eating disorders are primarily psychiatric disorders. The obsessive thoughts about food and weight combined with the shame associated with body image and negative self-esteem are the heart of these illnesses.

However, all eating disorder symptoms have medical consequences. The effects of chronic under and/or over-eating, purging, laxative/diuretic/appetite suppressant use all wreak havoc on overall health. Chronic medical illness is very rarely a motivating factor in recovery since the underlying thoughts are not logical but obsessive in nature. Through the recovery process, it’s critical to manage and maintain health as much as possible.

The worst and most common medical conditions caused by eating disorders are gastrointestinal. A few of these problems are the most common and also intractable.

Long-standing food restriction slows down the entire gastrointestinal system. This system is one long tube. Muscle contractions starting with swallowing then lead to a long contraction through the entire tube. That’s how food moves through our bodies. Food restriction slows this down considerably and leads to what is called motility dysfunction, namely gastroparesis (slowed digestion in the stomach) and colonic inertia (food getting stuck in the colon). These illnesses lead to chronic fullness and bloating which makes it hard to eat regularly, even if someone wants to try to get well. There is treatment for both, but since the primary issue is the lack of food, nothing heals motility issues more than eating regularly again—a catch 22 for people with eating disorders.

The other most common gastrointestinal problem stems from laxative abuse. These medications stimulate the colon to expel stool and excess water and achieve temporary weight loss by dehydration but does not lead to sustained weight loss. However, chronic use leads to long term damage by weakening colon function to the point where, at its worst, normal bowel function is no longer possible. Instead, the damaged colon causes chronic, painful diarrhea. Often stopping laxative use will lead to significant recovery, even after long-standing use, but permanent damage is possible too.

Although these are the most common and severe gastrointestinal effects of eating disorders, there are other less common ones. Even more so, some simple eating disorder tricks cause significant distress. Bloating and gas are common and often result from overeating vegetables or fiber or chewing gum throughout the day. Various artificial sweeteners can act as a laxative when eaten to excess. Drinking too much coffee or soda frequently leads to bloating and nausea due to the caffeine and/or bubbles.


As recovery progresses, it’s important to pay attention to and manage all medical problems causes by an eating disorder but especially the gastrointestinal ones. Being sure a person’s body functions well helps recovery go forward and also enables that person to fully engage with life as they get better.
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One question I have been asked several times is why most people with eating disorders are women. The answer has two parts, the first relates to the role our society plays in eating disorders and the second biology.

The obsession with thinness in our culture has been all consuming for decades. Despite increased interest in the sexualization of men’s bodies in recent years, all the focus has been and remains on girls and women.

The media has idealized thinness and has equated it with success for girls and women for decades. The endless array of photos of girls and women all focus on body size and shape and the privilege accorded to those women. Women’s clothes are often extremely revealing, and status is clearly awarded to those who meet the cultural expectation. The diet culture is aimed squarely at women, and a large majority of women struggle to see any other success as more important then body image and weight.

The result of the onslaught on girls’ and women’s self image and body consciousness is an enormous pressure to diet. As I have written extensively in this blog, the number one trigger for an eating disorder is dieting.

Food restriction kicks off a powerful starvation response first rooted in our biology: our bodies are programmed to adapt to a famine by minimizing energy expenditure and slowing metabolism to survive. Long-standing food restriction triggers a more powerful genetic adaptation to prolonged famine: obsession with food, preoccupation with finding and hoarding food, more permanent metabolic changes and sacrificing less necessary body functions.

Some people respond quickly by developing an eating disorder. Others discard the diet quickly and resume normal life. The decision isn’t conscious but based on how our bodies are designed.

The interesting caveat is that men would develop more eating disorders if the pressure for thinness and dieting was stronger for men because these biological adaptations are the same for men and women.

Instead, the societal pressure on women that have led to the rapid rise in the incidence of eating disorders appears to be a cultural means to force women to expend an enormous amount of energy on the meaningless task of weight loss at a time when their plate is already full: ambitious career goals while still managing other roles always burdened on women. 


It is difficult not to wonder if the increasing pressures that have led to eating disorders reflect a relatively new way to overload women in the current societal climate. The way to change this blight clearly is decreasing the pressure for thinness—a possible but difficult task for a goal so ingrained in our culture.
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Dieting is the main risk factor for developing an eating disorder. When someone begins a diet, they risk triggering an adaptive mechanism humans favored in times of extended famine. Those who could survive with limited food the longest persevered and their genes were passed on. So the starvation response is built into our genetic code and, when used in maladaptive ways, becomes an eating disorder.

Now, the trigger is no longer the lack of food but instead the driving force of thinness as a necessity for success in our modern culture. As long as thinness is a triumph, as long as fat bias exists, as long as the exercise, diet and food industries bombard the public with false messages, the masses will pursue thinness and diet.

Trapped in this funhouse where we are taught to see the distortion of our own bodies, people spend countless days, hours and years expending enormous mental and emotional effort on dieting and weight. We may worry about decreased productivity due to smartphones, but we ignore the endless lost time to weight preoccupation. 

The inexorable pull to thinness and weight loss is pervasive in the culture through urban and rural parts of the world, socioeconomic differences and racial and ethnic communities. At this point, no one is spared.

In addition to the personal and interpersonal changes I have written about in this blog that can help, eating disorders will not begin to decline without a decrease in the pressure for thinness. There are some signs of positive change: the body positive movement, outing of fat shaming, and varying size models for some clothing companies. These changes matter and are noticeable in the community.

But for more change to occur, the true arbiters of personal success need to speak up. Celebrities across the board need to question the overall thin bias and stop supporting the industries that benefit from our collective obsession. The medical community needs to be clearer about the true minimal link between weight and health. The government needs to crack down on industries sapping our mental wellness to live a life lost in pursuit of the number on a scale.


The effects have been long lasting and harmful. The changes that need to happen are starting. If a different way of assessing our own success begins to grow, the power—financial and emotional—of the thinness crusade can be weakened.
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One post I wrote posited that love is the antidote to an eating disorder. I’m rethinking this concept. Perhaps, a better way to understand this part of eating disorder recovery for many people is that feeling unlovable is at the core of many people’s eating disorders.

It’s not uncommon for children to interpret challenging formative experiences as signs that they are unlovable. For some, it is a stage they flounder in until they find value in themselves as they get older. This self-worth can translate into feeling worthy of love.

For others, the core of unlovability grows into something with deeper roots in one’s psyche. Adolescence, especially for girls, is very frequently tied up with looks and self-image in our current culture. When the lack of self worth is matched with a powerful urge to perfect one’s looks, two things happen.

First, the risk of an eating disorder goes up significantly. Equating personal value with body image sets up a constant desire to lose weight or perfect looks in order to escape the feeling of not being lovable. However, this battle can never be won.

Second, the growing power of food and weight and the impossibility of fixing the problem justifies the fact of being unlovable. Since this person can never achieve her goals, she will always be unlovable. This is no longer an internal feeling. It begins to feel like a fact.

And so treatment for an eating disorder often involves countering this belief that, at the core, the person is unlovable. Separating self-worth from body image is a part of recovery that is very much achievable, if long and hard.

But convincing someone that they truly are lovable underneath is even harder. It demands an intensity in the therapy to question how someone sees themselves. And it puts pressure on the therapy to essentially prove that the eating disorder has always been wrong.


This work in therapy is very much possible. It demands a consistent treatment structure, significant trust and a complete understanding of the issue at hand. With these three pieces, therapy can undo the underlying and usually long lasting belief of feeling unlovable and free the person from this self-doubt that has often dominated their sense of self.
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Eating disorder treatment needs to include some focus on food and eating patterns. Even though these illnesses are primarily psychological, restricting, binging or purging all cause disturbances in thoughts and emotions. Addressing the eating patterns is still critical to recovery.

In most treatment, the expectations around how to monitor eating is standardized. There are clear methods to track food: food logs or apps like recovery record. But many people don’t find these strict programs to be useful. They can feel limiting, infantilizing or restrictive. Even if someone has an eating disorder, that doesn’t merit being treated like a child.

In these circumstances, it’s easy for treatment to focus more on the eating disorder thoughts and frustrations of having a chronic illness while sidestepping the need to track food and eating behaviors. However, no one seeking treatment wants to avoid a necessary part of success. Instead they need help finding a different and more palatable way to monitor food.

A clinician needs to try to meet the patient where they are and respect their needs. Revealing the details of daily food intake is incredibly exposing for someone with an eating disorder. Nothing is more personal since food is at the center of their lives. Accordingly, they need enormous respect and understanding about setting up a way to follow food. It may seem simple to the clinician but could not be more difficult for the patient.

A conversation about food journals needs to start with flexibility. There are so many ways to track food: written logs, spreadsheets, apps, emails, texts, photos, voicemail. Given the options, people are more likely to think about what would make a regular log possible. Often people would prefer to send it off daily in some form so they don’t have to review their food for the last few days or weeks. Ease of communication is central too. Many people have trouble overcoming the idea of spending a lot of time on a log.


Also the flexibility of how to make a log sets the tone for treatment. It implies there is not just one way to do things. Overall the idea is for someone to recover. There is no right way, just the way that works.
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