A major debate on the topic of eating disorders today is the addiction perspective versus a psychiatric or traditional model. Marty Lerner, PhD, CEO and Executive Director of Milestones In Recovery, Inc., spoke today at the National Conference on Addiction Disorders in Orlando, Fla. and shared his thoughts on this debate.
He said first of all, when a person comes in with an eating disorder, it’s important to figure out what what level of care is really appropriate for that individual. He said these disorders should not be treated like a “one size fits all” treatment. The decision could be to put the person on a medical floor in a hospital, a locked psychiatric unit, day treatment, residential treatment, or other option.
Lerner said that he rarely sees someone “with a unified diagnosis of an eating disorder without a comorbid or co-occurring issue like a mood disorder.” He continued on this thought and said that a third or more of the patients they see for eating disorders have problems with chemical dependency or chemical abuse issues.
He then went on to list the most frequent issues that he usually sees occur in a person with an eating disorder:
· Mood disorders 70-90% (Most are major depressive disorders and most are recurrent, he said.)
· Substance abuse/dependency 40-60%
· Personality disorders 20-30%
· Attention deficit disorders 20-30%
· Other issues include self-injury, perfectionism, PTSD, spending/shoplifting, compulsive approach to work or school
Another topic in his presentation had to do with the idea that certain substances in foods, such as sugar, white flour, high glycemic and highly processed, can be addictive. Here he looked at the two sides as looking at addiction with eating disorders from the perspective that substances may be addictive versus what people call intuitive eating based on the assumption that people need to and can learn to delineate through a number of different techniques. What he means by this is the decision of the person intuitively to determine what they need to eat, when to eat, how much to eat, when to stop, etc.
He also talked about the latest research that has been done which is on the destruction of D2 receptors. This research, he said, shows that they’re destroying the receptors. Although the receptors can regenerate, the tolerance goes up when this happens. Therefore, it takes more of the same behavior and/or same substance to get the same effect.
The psychiatric model, he said, “assumes an underlying issue that requires insight and ‘working through’ or cognitive ‘restructuring’ as a pre-requisite to recovery.” It also “approaches food/weight issues via ‘intuitive’ eating and/or learning to control either binge foods or ‘forbidden/bad/high calorie’ foods,” according to Lerner. He made the comparison that this approach is much like teaching controlled use of a substance.
His major concern with this model is the measurement device. “In my humble opinion, the poorest means to measure acuity of an eating disorder is body weight,” he said.
He recognized that there are going to be outliers like someone 5 feet 5 inches weighing 60 lbs or someone weighing 400 lbs, and he said that in those scenarios, the measurement method is relevant. “But 99% of the population we treat are not at those extremes,” he remarked.
“Looking at drugs and alcohol as an analogy, it’s long been said that the frequency and amount that someone drinks is not a good measure of whether they’re alcoholic or not. It’s what happens to them when they do drink,” Lerner said.
On this note, he said that the most effective way to assess eating disorders is to look at the extent to which the eating disorder interferes with quality of life and functioning.
He has concerns with the addiction model as well saying that that model usually involves a structured food plan which limits or eliminates “binge foods”/addictive behaviors (rituals). He said that people also criticize this model because it does not offer a “cure” and requires a lifelong commitment to recovery.
He discussed a blended addiction model assumes that an eating disorder is an addictive process with physical, emotional and spiritual components; assumes “disease” is life long with periods of prolonged remission and often punctuated by relapses followed by continued recovery; and that may incorporate cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT), mindfulness, medication, and relevant 12-step community based support groups.
He mentioned that there is a new phenomenon called “Anorexics and Bulimics Anonymous” (ABA). He also said that at his center they promote an eating plan that strives for three to five small meals per day. “Real treatment is in the root of 12-step groups,” he said. He said that he likes to think about treatment in the acronym “SERF.” The SERF components for people in recovery include:
· Food plan
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