It's Been a Long Wait.

In an article entitled "Anorexia Nervosa - Irony, Misnomer and Paradox", which appears in the May/June edition of the European Eating Disorders Review, Drs. Bryan Lask and Ian Frampton question the strong emphasis placed on weight, BMI, and targets by professionals treating and researching anorexia.

Hurray!

While their article focuses largely on the inadequacy of weight as a one-stop, valid and reliable indicator of good physical health, there are plenty of reasons why excessive preoccupation with weight is just about the worst thing for anorexic patients and the clinicians treating them to have in common. The collective obsession with weight: destroys therapeutic alliance; promotes feelings of failure, frustration and guilt in some if not all parties involved in treatment; reinforces patients' belief that weight is far, far more than just a number on a scale; creates any number of diagnostic inconsistencies; and, perhaps most importantly, prevents the discussion from moving on to whatever else may be going on in patients' lives.

It's easy to see why treatment might descend into a weight-fest. First of all, severely emaciated patients encourage a triage mentality, the clinician's most pressing concern being to restore the person in front of them to a state of physical safety. From a medical standpoint, this absolutely makes sense. There is also an accompanying psychotherapeutic rationale: the effects of starvation mean that under a certain weight patients' are particularly intransigent with regards to their "anorexic thinking" and thus, so the argument goes, talk therapy is unlikely to be effective. (This in itself could be the subject of several blog posts). Then there's the fact that -among the many other beguiling features which may or may not contribute to a given patient's illness- weight is a ubiquitous theme, and a concrete and readily measured one at that (albeit, as Lask and Frampton suggest, one with notoriously poor inter-rater and test-retest reliability).

However, to start treatment by talking about weight, as is the norm, risks getting off on very much the wrong foot. The patient is already likely to feel fat, threatened and terrified at the prospect of any sort of change in any aspect of her* life. How might she respond to the clinician's message that she needs to put on x kilos of weight, and that this Body Mass Index (BMI) table grants him** the authority to say so: "Nice to meet you, too"? A common theme of anorexia is a desire to own one domain in a life which otherwise feels out of control: if a patient is seeking to assert her individuality by controlling her weight, she is (to borrow a little anorexic thinking) unlikely to respond well to the demand to eat her way into a bandwidth representing "normal" on a population distribution.

A strong emphasis on weight early in treatment, when the patient probably finds it very hard to see herself and her illness as two distinct entities, can thus rapidly descend into the drawing of battle lines: in one, camp the frustrated clinician who'd probably like to move on to other aspects of treatment but is bogged down with the weight issue; in the other camp, the outwardly defiant/inwardly terrified patient trying to outlast him. In the case of most adolescent treatment, a third party is added to the mix: the hapless parent/caregiver bounced back and forth between the two. Parents charged with day-t0-day responsibility for refeeding and weight gain may face their anorexic child's hostility, anxiety and fear on the one hand, and on the other a tremendous sense of guilt if prescribed targets are not made. This guilt is likely to be internalized by the patient, so entrenching her illness still further, and so on and so forth.

Beyond fostering guilt, resentment and mistrust there is another important way in which a weight impasse may support a function of the illness: by preventing discussion about anything else. Patients who are burying a host of uncomfortable emotions and feelings in their eating pathology may be quite comfortable keeping the focus on weight, weight and weight alone. This may be occurring largely at an unconscious level, and a weight-focused treatment is likely to ensure that it remains so. On the other hand, in patients for whom the illness may be a "cry for help" (and who might well overlap with the emotion-buriers) anxiety over putting on weight may include fear that once they reach their target they will be pronounced well, without other, underlying issues having been addressed. (In their article, Lask and Frampton present one possible scenario of this kind: the inpatient who avoids putting on weight in order not to return to an unlivable/abusive home situation).

The preeminence given to BMI as a diagnostic criterion for anorexia in both the DSM and ICD taxonomies is at least partially to blame for the field's excessive emphasis on weight (and another source of many potential blog posts). While one may debate how the DSM's "Refusal to maintain a body weight at or above a minimally normal weight for age and height... e.g. 85% of that expected" and the ICD's "Body weight is maintained at least 15% below that expected" should be interpreted in the case of patients already in treatment, the fact remains that the corresponding BMI of 17.5 remains a standard commonly used in both clinical practice and research for what constitutes ill. For many patients who are gaining weight in treatment but still consumed with anorexic thinking, whatever number on the scale equates to that cut-off, it is likely one they fear reaching.

It is of course all very well to say all of this -especially when one has the comfort of not being a clinician sitting in front of a perilously underweight man, woman or child for whose physical, as well as mental, health one is responsible. Indeed it would be irresponsible (not to mention professionally negligent) to allow a dangerously thin patient to remain that way. However, while ensuring a patient's physical safety is one thing, framing treatment around weekly weight gain and a target BMI is altogether another.

Increasingly, clinical approaches for particularly treatment resistant patients have begun to move the emphasis away from weight; while reaching and maintaining a safe weight remains a key feature of treatment, adequate nutrition is framed not as an arbitrarily imposed target but a necessary practical condition to allow the patient to work on other aspects of recovery. Some clinics opt not to tell patients their weights at all on the basis that any number will simply provide further ammunition for the illness (although weight is monitored regularly along with blood pressure, temperature etc., to ensure adequate physical health).

Moving the discussion away from weight has a number of potential advantages, to include: improving therapeutic alliance by making the patient feel heard and understood; making space in treatment to discuss other aspects of the patient's illness; reducing the manipulative, subversive and confrontational patient behavior that the weight battleground often generates; encouraging patients to begin to explore (without the foil of weight) who they are and what they really want beyond their illness.

These approaches where weight is less emphasized are often reserved for "chronically" ill adult patients who have relapsed many times, and who -far more than adolescents- are in a position to cease treatment if they do not like its terms. However, promising outcomes with this difficult-to-treat population suggest that maybe it should not take all other treatment options failing for the field to summon the courage to move some of its emphasis away from weight.

This doesn't mean that "nutritional restoration", as Lask and Frampton phrase it, is not essential: rather that the assessment of minimum healthy weight should be guided not only by BMI but also by other indicators such as menarche/resumption of menstruation, blood pressure, electrolyte balance etc. that represent a more personalised assessment of the patient's overall health. A more balanced and sophisticated assessment of nutritional restoration reinforces an emphasis on recovery rather than refeeding, the aim being to provide the patient with the prerequisite physical health to have every option available to her as she decides what she wants moving forward during and after treatment (in case becoming a professional surfer is high on her list).

So, what would it take to assuage the field's current, excessive preoccupation with weight? Lask and Frampton call, among other things, on eating disorder professionals to broaden their minds about indicators of good health, and urge them to find other ways to cope with their own anxiety about the need for an easy measure of adequate progress. However, this mandate is not reserved for clinicians alone. It extends to health authorities, insurance companies and other funding sources looking for justification of treatment costs. It includes researchers designing clinical trials and measuring treatment outcomes (and maybe even the members of the work group adding the finishing touches to the DSM-5). In the meantime, here's to Drs. Lask and Frampton for so publicly raising the issue. It's been a long wait.


* How to ascribe gender to hypothetical eating disorder sufferers is, I can see, going to be an ongoing problem in this blog. To avoid excessive and always annoying "him/her" and "his/her" repetition, where gender isn't obvious my hypothetical anorexics, bulimics, and binge-eaters will be referred to in the feminine. I do this biting my tongue (keyboard?), because the fact that eating orders affect both sexes contributes a great deal to my sense of what eating disorders are about.

** To complete my duet of incorrectness (political or otherwise), by way of contrast my hypothetical clinicians will be referred to in the masculine.