Eating Disorders for Psychiatrists: Part 1

Preston: [00:00:00] Who I was concerned that I had an any disorder. I was like, have you ever used laxatives to induce weight loss or misused like diuretics or taking caffeine to suppress your appetite? And they were like, caffeine can suppress your appetite. And I was like, uh, no. No, I can't. And they were like, they were like, dang, you could do that.

And they were like, oh. And they. And then she's like, I never thought of the laxative thing either. Thanks. And I'm like, no hypotheticals. Whatcha talking about?

Margaret: Welcome back guys. This is Margaret 

Preston: and I Preston, 

Margaret: and we have a very special guest with us today. Who is my med school best friend, light of my world. Dr. Helen Al. Helen, do you wanna introduce yourself? Sorry, doctor. Um, 

Dr. Helen Liljenwall: my name is Dr. Helen Lial, also known as Margaret's best friend and also she is my best friend and I'm really excited to be here today.

Margaret: Preston, do you know that Helen is the [00:01:00] reason that we met the first time in real life in San Antonio? 

Preston: Oh, it was, it was your wedding. 

Margaret: Yeah, it was her wedding. That makes sense. That was my wedding. Mm-hmm. When Stars July. 

Preston: Yeah. Y'all are really close. I feel like I'm like already intruding on something. Yeah, 

Margaret: just three best friends, you know.

Well, okay. I'll say Best Preston, I'll tell you this so you feel more included. When Helen found out that I knew you, she, and then I told her about the podcast. She was like, wait, literally she was silent for like a minute and was like, you know him. You know the, so. 

Dr. Helen Liljenwall: I was really into your, um, your med school videos.

I had sent them to Maggie a couple times, and then also, um, so we have a little bit of a Parasocial relationship that you're unaware of, but now you're aware. Yeah, I was a big fan. I You have a, a great, uh, like comedy video thing going on. 

Preston: Thank you. Yeah. My, my comedy chops are. They what? Put me on the map, so to speak.

Yeah, I noticed [00:02:00] that was, but now I'm just here to, now I'm up. 

Margaret: That was a big fan. Um, okay, so today we're talking about eating disorders and Helen is coming on because Helen has both experienced clinically as well as from a systems, systems level in terms of organizing how we get people care. But before we talk.

Clinically eating disorders. Defining, I thought we might start with the positive side. Uh, this weekend Preston and I were at a PAA, the conference and I went to a few nutritional psychiatry lectures. And one of the questions, uh, Dr. Ramsey had put in his lectures about how he talks to his patients is asking them like positive memories about food or foods that they love, recipes, they love to get nutrition and just in general.

And so I thought we would start with a fun food question, which is like. What is a food that is associated with positive memories or connection? People? Culture one food for each of us. 

Preston: So, and I think it's an important context here that Dr. Ramsey told [00:03:00] us, like his inspiration for that comment, which was that he was, would bring his patients into clinic and then would always ask them about the negative things.

And he had one patient that was like, are you gonna really gonna ask me something positive or nice? Or do I just come in here every time? You just shit on me. Like, what did I ever do to you? You know? And he was like, oh my God, they're so right. So it, so it was really, it was, it was a patient's idea that Dr.

Ramsey took on because we are pretty negative as doctors. 

Dr. Helen Liljenwall: Yeah. Actually, I feel that really intimately. I talk about that with my patients. I always try and end, not even end, even the middle, like try and bring, bring up something positive because yeah. Then we're just like, okay, and now tell me about your depression and then moving on, let's 

Preston: do our rose bud thorns really quick 

Dr. Helen Liljenwall: little rose thorn to, to get it started.

Preston: Yeah. Since I started first my Rose or is actually, um, it's a rainbow because I'm, I'm eating Lucky Charms right now. 

Margaret: Hmm. Pressing the food question. [00:04:00] 

Preston: There's a single food that gives me like, probably the most happiness and Lucky 

Margaret: charms. 

Preston: Yeah. 'cause this, it like associates with whatever activity I'm doing.

I do like, I like to eat dry mug cereal. I. Ever since I was a kid, it was a big comfort of mine to like play Xbox while I'm eating dry cereal. And now it's like become this like conduit for productivity. Like whenever I wanna focus on something for a long period of time, I know I have like my little mug of Lucky Charms that I'm gonna kind of just keep trotting along.

So it's, it's not to suck gourmet food. It's not anything like that I look forward to all the time. It's just like something that, that to me means like kind of productivity and comfort. 

Dr. Helen Liljenwall: Actually really relate to that. Preston cereal is not my food, but in college I was actually known for eating a lot of cereal to the point that my 21st birthday party theme was Cinnamon Toast Crunch.

Preston: Awesome. Cereal's awesome. 

Dr. Helen Liljenwall: My favorite food. Um, I've been thinking about this for a couple minutes. Like, I feel like [00:05:00] the, the food that brings me back to childhood most is, um, specifically homemade chocolate chip cookies. Like the Tollhouse recipe, I have it memorized because like my family just like whips it out all the time.

We eat it for like dessert and just like snacks and like that fresh cookie always brings me back to childhood. So 

Margaret: I love that. I love that you both have the like childhood comfort suite. That brings you back. 

Preston: Yeah. Food and nostalgia, travel so closely together. 

Margaret: Mm-hmm. 

Preston: Like nothing, like a smell to bring you back to an old memory.

Margaret: Mm-hmm. I think mine is this recipe that I, Helen, I think you've had this before in med school, which is this pasta recipe that's macho, that is mm-hmm. From, um, it's just like a specific sauce that's based on this restaurant in St. Louis Azis that my parents used, used to go to when my dad was there for med school.

Um, and they could spend like a couple bucks and get these like massive things of like garlic bread and this [00:06:00] pasta when, uh, they were broke and he was in med school. And my dad has been trying to make this recipe for now like 50 years to like get that moment of the relief of getting food. For cheap bye to the cat or cheap when he was in med school.

And so we make it I think like once a month and would make it in the summer. And like all of us have baby pictures of us just like covered in like the red MAA trolley sauce and like it is the thing I make whenever I have to cook for a lot of people. So I think that's like connected so much for me to like family memory and family gatherings and also just like I do like it.

It's good. Helen's had it. 

Dr. Helen Liljenwall: I've had it. It's delicious. I was like, 

Margaret: you're gonna lie now if it's not good, but actually it's disgusting. Nevermind. It's gross. It's gross. And that's that. Alright, well thanks for coming on. Yeah. Alright. This 

Preston: it's has been real. All right. I'll see you next time. 

Margaret: So I guess one of the reasons I wanted to start with this question was to talk about like why with eating disorders, I think it's also [00:07:00] important to talk about.

Not just getting rid of symptoms, but the positives that people lose when they're like deep in an eating disorder. So this is part one of eating disorders and we are going to kind of start with examples of different ways that eating, feeding body image disorders are shown in popular media and kind of go from there as looking at cases.

Yeah. But first we'll do a little bit of review. Um, but first we'll take a quick break and we'll be right back.

Hey Preston, what does the sound remind you of? Oh 

Preston: God. It, it makes me think about being on call. It's the pager. 

Margaret: Okay. Well it's not my pager, but it is equally stressful. And is the timer I use for studying? 

Preston: Oh, we got a Pomodoro queen over here. 

Margaret: Do you know what is made studying Less stressful though. 

Preston: What 

Margaret: Now?

You know, psych, you familiar? 

Preston: Am I familiar? I, I use ninoy for my in-training exams. Are, are we talking about the same thing? That excellent resource that has thousands of [00:08:00] questions with associated flashcards, organized content in a user-friendly way. 

Margaret: You use it for pride. I'm using it for the board exams.

But yes, we are talking about the same resource. We, 

Preston: we can use it for both. Ao 

Margaret: Ready to take your exam prep to the next level? Go to now, you know, psych.com and enter the code. Be patient at checkout for 20% off. That's now you know, psych com. 

Preston: Hey, so I wanna talk to you about this new podcast I think every clinician should be aware of.

It's the sepsis spectrum from Sepsis Alliance, and it's done by this great critical care nurse, Nicole Kubic. 

Margaret: You may be asking why are two psychiatrists talking about sepsis? But if you've spent any time, uh, in the hospital where psychiatrists or mental health practitioners go, you know that whenever someone's mental status is altered, we can be called and.

Not knowing the signs of sepsis, whether that's in the ICU, the ED or other places in the hospital, can mean that we're missing things alongside the team for things that'll really impact our patients. 

Preston: Yeah, I mean, delirium comes on quick and fast and you have to keep it on your differential. It's hit me on the [00:09:00] the inpatient psych floor and mm-hmm.

Even for nurses that work in mental health and don't think they're gonna come across this stuff, it's gonna come across you. So it, it's important just to, to keep it on your radar, and I think this is a great resource for it. So if you want, you can listen to the sepsis spectrum wherever you get your podcasts, or you can watch it on Sepsis Alliance's YouTube channel.

Margaret: To learn how you can earn free nursing CE credits just by listening, visit sepsis podcast.org. That's S-E-P-S-I-S podcast org for more information.

I guess, Helen, what do you think we should do? Do you wanna start with cases or we should we start by basics for our listeners on the different kind of categories of eating disorders? 

Dr. Helen Liljenwall: Why don't I do like a quick run through basic of like what each disorder is briefly, so that we can kind of have a little bit of an idea of where we're coming 

Preston: from land.

Dr. Helen Liljenwall: You know, there's a couple of different kinds of eating disorders, [00:10:00] and the first one that I think everyone kinds of thinks of when we say eating disorders, um, which is the most deadly one, is anorexia nervosa, which kind of has three components. The first one is kind of like a restriction of energy intake relative to the amount of requirements that your body has.

And then with that, a like low body weight relative to kind of your expected age, like where you're at in life. Um. Which kind of relates a little bit to atypical anorexia nervosa, which I'll get to. Um, part two is kind of like a fear of gaining weight, and then something that I think people talk less about but is more relevant for like younger kids is behaviors that interfere with weight gain that can also, so it's an either or that can also kind of get you a, a mark on that one.

And then the third part is a disturbance in body shape, like, you know, wanting to have like. Not really recognizing like how thin your body is, but then with that, um, it can also be the [00:11:00] or and or of a lack of appreciation of, um, your symptoms and how sick you actually are and the relationship mm-hmm. Of that restriction to that.

Which also kind of gets at, like with the younger kids, they don't really usually like talk about like a disturbance in body shape. It's usually like, I wanna be small. It's not like, you know, um. 

Preston: It's like, what's the problem? Um, yeah, that I've seen. Yeah, that last one is so real and yeah, I think is like, makes it so hard to treat.

Margaret: What is your experience? 'cause you are a child, psychiatry, second year fellow. Yeah, as of July, I, yeah. Sorry, I should have 

Dr. Helen Liljenwall: added that context in my intro. I'm our listeners 

Margaret: hate context and so do I. Um, what has it been like for you to go from adult residency and seeing adults to being a child for the past year in terms of how these look?

Um. Kids and how kids talk about it when they're sick with this versus like a 22-year-old. 

Dr. Helen Liljenwall: It's really different and it's also the same. [00:12:00] I think the difference, um, a lot of it comes and it's, it's hard not to see it from this lens that like there is just so much great multidisciplinary care for kids and it just does not exist for adults.

And so by the time that you're seeing the adults, a lot of times they've been sick for a while. Not often, but a lot of times. And then where I found a lot in my adult training, all of the true, like patients with anorexia that I saw were on the inpatient medical floor. So inherently they were medically ill.

And then with kids, um, you know, I see them in an inpatient setting, a partial setting, an intensive outpatient setting. And so I see them kind of more in like a spectrum of recovery. Mm-hmm. And then also, you know, like the way that I was kind of alluding to this too, the way that people kind of talk about their body and a lot of the influences that kind of led to the disorder is a little different depending on what treatment setting you're in.

Margaret: [00:13:00] Yeah. Yeah. Is there words that kids use, like if you see like an 11 or 12-year-old versus like how adults, like how you were both you and Preston were both saying kind of like, yeah, they will describe it differently or they won't have the same words that describing their like body dissatisfaction that like someone in their twenties or thirties or beyond might have.

Dr. Helen Liljenwall: Yeah, and I think, you know, I hate to use kind of like. Triggering language like this with like, but like older adults, like, they'll be like, sometimes they'll be like, well, I wanna see my ribs, I wanna see a thigh gap, right? Mm-hmm. Like, they'll kind of name specific things. Usually, hopefully a 10-year-old is not in a developmental stage in which that is remotely on their radar, right?

It might be, oh, I wanna be small, like I wanna be tiny, but like, what does that really mean to them? It's not like I wanna be skinny, right? Yeah. 

Margaret: How long do you think it takes kids to show up? Obviously adults it can take much longer. People can live with for years with it. Mm-hmm. But do kids show up [00:14:00] right away to treatment or like what is the kind of your experience been of the onset and then time to seeing mental health care providers around it?

Dr. Helen Liljenwall: Oh, it's so dependent on the environment because I think, you know, if they have a really good pediatrician, sometimes they'll catch it, parents will catch it. But you know, like it's, it, it depends like, you know, when kids are at school, if they have a lot of activities, parents don't notice if they're skipping meals.

Mm-hmm. Um, and so, you know, what I'll notice is like, you know, if meals aren't had together, like you don't really know what your kid's eating. Um, I will say for kids, you know. My bias is that I see it when it's caught because I'm treating them 

Margaret: right. Fair. You're not vigilant out. I'm not. I'm recess. 

Dr. Helen Liljenwall: I'm not al walking through the neighborhood like, do you need a psychiatrist?

Not checking 

Margaret: their lunchboxes for a single package of special K. And that's it. [00:15:00] 

Dr. Helen Liljenwall: Yeah. And then, you know, for the adults it's, it's just a little different because, you know, when they're on the medical floor, where I saw them mostly, and that was my bias, was when they were getting admitted for something else.

Preston: Well, it sounds like what you're saying is the kids have someone who's watching over them. Mm-hmm. And there's someone else that may intervene, but once you're an adult and you're taking care of yourself, the only, if you're not interested in seeking treatment, like we talked about, the only way you'd interface is if you're getting to the point where you're so medically sick that you have to be brought into the hospital.

Dr. Helen Liljenwall: Yeah. And sometimes people will have the insight to, you know, get care, right, and or mm-hmm. Like the motivation. Um, but it does take a lot of like family involvement often, you know, anorexia in itself is ego syntonic, meaning that, you know, you want to align with a lot of the thoughts that you're having.

Which makes it particularly difficult when you're trying to parse out with an adult, what are their values? Like if we're talking about capacity [00:16:00] and competency, right? Because their value is to be skinny, inherent in the nature of the disorder. 

Preston: Mm-hmm. I, I guess I was just gonna say like it, I'm putting this together, but you know how, um, SSRIs are not indicated primarily for anorexia?

Mm-hmm. And I guess thinking about that. In addition to other things, um, like a, a medication is not going to disrupt ego syntonic thoughts. It won't change your values. 

Dr. Helen Liljenwall: Yeah. I mean, and the thing is for anorexia, food and nutrition is medicine. That's the best evidence-based medicine. And so, you know, it's, it's kind of like they, they took, there's a lot of work on adults with eating disorders.

That kind of looks at if they feel coerced when they get on the psychiatric unit. And a lot of times they do, um, in the first week, and then I think it drops by something like 20% after the second week [00:17:00] when they're there. Um, and get a little bit of nutrition because as you get nutrition, you can start to build a lot more insight, um, in the disorder.

Preston: And so how does bulimia differ now from anorexia? Mm-hmm. 

Dr. Helen Liljenwall: Yeah, so I think this is a, a confusing point because within anorexia there's two types. There's a binge purge type, which is where, you know, we see on tv, um, you know, like the throwing up or like, um, you take laxatives and things like that. And then you also have episodes of being out of control, and there's also a restricting type.

But when you see someone like throwing up, you think bulimia, right? Because that's kind of like where we go to with anorexia, kind of that, that weight loss kind of goes along with it. But then with bulimia, you can kind of feed into both. And so you cannot have bulimia if you have anorexia. But someone with anorexia can develop bulimia, like [00:18:00] kind of throughout recovery or, um.

Not like. Yeah. And so in bulimia you have episodes of the binge eating, like feeling out of control, um, and then the compensatory behavior, whether it be restricting for a day, throwing up laxatives, things like that. Mm-hmm. Um, that'll be your purge. 

Preston: So, so am I incorrect in saying, okay, if we have this binge and purge subtype of anorexia and then we have bulimia is the only like differentiating like line between them the BMI cutoff.

Dr. Helen Liljenwall: So it's not BMI. And that is, I think, where it's a little different. So I think the way that eating disorders are kind of diagnostically, I. Put together in the DSM in itself is a little controversial 'cause we'll go back to anorexia. The way you d determine severity in anorexia is with your BMI, which is kind of nonsensical when you actually treat anorexia in the first place because sometimes people who are at a [00:19:00] very low BMI present with a lot of insight and they're very motivated and they progress in treatment very quickly.

And then some people who are at a higher BMI or even at like, um. In a larger body, um, where you might have atypical anorexia and they still have that weight loss, have very severe eating disorder thoughts and behaviors. Um, and then bulimia, you're kind of like stagnant in your weight in the way that I understand it and that like you're not.

Stepping below your growth curve, which is kind of how we determine someone's ideal body weight, is you look at the historical trends of where they've been on growth curves, like what weights they, and heights they've been historically at. Um. And then you kind of determine SVE severity in bulimia by the number of episodes of binging and purging.

[music]: Hmm. 

Margaret: What did there used to be an E, like A BMI cutoff that differentiated them? Like if you were be or is it only ever been or recent times the severity in anorexia? So basically [00:20:00] if someone's, I guess I think, here's where I was mixed up. If someone's BMI goes low enough in bulimia, then they are. Anorexic and they can go back into bulimia once their BMI maybe is not in like that range.

Mm-hmm. Um, that was the thing I think that used to confuse me was like that there is. Yeah, I mean also like how it still confuses me useful is that it still me, me. Question mark. How clinically useful is that? No, I agree with your assessment. It's also like, this is so like, like it's like okay, now you're this like what is, I'm sure there was a reason when they split them up by this for like diagnostic categories to study by.

Yeah. But it seems kind of arbitrary now. 

Dr. Helen Liljenwall: Yeah. Especially when you're talking to insurance companies and someone's like, technically. Weight restored because they're at their ideal body weight, yet like they're still having really severe thoughts and you're like, well, they still need treatment. [00:21:00] Right, right.

Just because you've determined that they've reached this body weight. Yeah. 

Margaret: And how often, like with bulimia does like the purging or these behaviors need to happen? Like is there a length of time these things happen can have to happen before for these conditions so far that, 

Dr. Helen Liljenwall: yeah. Bulimia, it's three months, and then at least once a week in order to qualify for the diagnosis.

And then if you don't meet that criteria either for anorexia or bulimia, that's where we have the other specified eating disorders. 

Preston: Hmm. 

Margaret: Is that the, is that the OED or O oed? Yeah. And then there's, 

Dr. Helen Liljenwall: which is unspecified, unspecified eating disorder. And. Honestly, I get them so confused because it 

Margaret: feels like the same word.

Um, I've been taught this before, that the unspecified in billing is like, this could be specified, but we haven't worked it up yet. Otherwise specified is like, we put them in the [00:22:00] categories and none of them fits. So in their, they're in this weird box. Like, it's like, it's like the catchall as the ed. Yeah.

O Fed is in the like, oops. We just don't fit them into a category and we probably have worked them.

Dr. Helen Liljenwall: Oo, fed is, is the bulimia, but like not bing and purging enough. 

Margaret: I don't know. Or for long enough. Austin is like the, like you don't fit into something and like you're staying in the, you don't fit in something category. 

Dr. Helen Liljenwall: Anyway, this doesn't matter. So 

Preston: you 

Dr. Helen Liljenwall: every two weeks oed something with oed, since we're talking about it, is with atypical anorexia nervosa, and this is a relatively new diagnosis that people are talking about is if you existed kind of at a higher.

BMI before, and then you drop weight really quickly and dangerously, you are still just as at high risk for the medical complications of eating disorders, whether you're coming in with those low BMIs, so you can still have like the [00:23:00] bradycardia, refeeding syndrome, things like that. And a lot of those, you know, anorexia behaviors, yet you didn't fit that typical diagnosis with the BMI cutoffs.

Yeah, 

Margaret: and this is where I think medicine can be quite guilty in terms of least in the past, praising behaviors that were not sustainable, unhealthy, and eating disorder. But if someone was unlucky enough to come in a larger body into the medical system, it would often be seen as like, oh, this is great.

Like you're losing weight, you're showing willpower, da dah, dah, dah. When in reality it may have been an eating disorder, not for everyone, but sometimes and wasn't. 

Dr. Helen Liljenwall: Yeah. And that's where a lot of the bias can come into. Like, you know, people being like, well, they don't need medical attention. And you're like, okay, that's just not true.

Um, so yeah. So 

Preston: anorexia, bulimia, ed, oed. 

Margaret: Mm-hmm. 

Preston: And aed. Okay. 

Margaret: [00:24:00] You should we do, should we talk about binge eating disorder? Oh, yes. I feel like that's in my mind related to bulimia. 'cause it's kind of like binge purge without the purge. Mm-hmm. Well, since 

Dr. Helen Liljenwall: you've already have diagnose, take it away Margaret. 

Margaret: Um, binge eating disorder is basically like, there's not purging behaviors.

Um, and is on the. Part of what my research was on in med school was like helping people with binge the binge eating disorder diagnosis with my mentor. Um, so it's more like the baseline instead of, if you think of anorexia as like the baseline intake via restriction or via restriction, approaching like baseline of calories is lower, causing weight loss into these severity ranges.

Bulimia is purging and. Sometimes then bingeing, although I feel like talking to patients, you have to actually really parse that out. Determine like to determine like is that a binge or are you just eating, you know, an 800 calorie meal because you haven't had any calories up until this point [00:25:00] in the day, but regardless.

Mm-hmm. And then binge eating disorder is more so the kind of locus is on the binges on top of like a norm, like a kind of maintenance normal B-M-I-B-M-I sucks. It's a normal kind of like, you're not restricting throughout the day, but there are times where this purge happens and there can be restriction, like food rules and a lot of like, I have to eat perfectly and you're eating enough calories through the day.

Um, but then there's still the purge or the, the binge at the end of the day, I feel like is the most common or with like, stressful parts of the week, parts of the day, depending on who you are. But, so an increased intake and often binge eating disorder is associated with higher BMI and weight gain. 

Preston: And I think you brought on something really important, which is the sense of like loss of control.

Yeah. Mm-hmm. During the binges. So there's like a specific kind of state of mind that someone enters when they go into these binges, which is, um, like characteristic different than other, other types of bingeing. 

Margaret: I feel like people will [00:26:00] often say they feel like dissociated or they feel like. Either hyper in their body and sensing it when they're binging or completely outside of it.

From like the dissociation standpoint. They, yeah, the Preston's. Right. In terms of like the feeling of being out of control, not being able to predict it. Mm-hmm. Um, they'll, people use the words like, I feel like a bottomless pit, or like, I'm never Not hungry. Food Noise also comes up with this, which we'll talk about a little bit later in terms of talking about like the rise of GLP ones and their place in eating disorders.

Dr. Helen Liljenwall: And then we have AIT just chomping at the bit here. Well, not 

really. 

Uh, not really. Yeah. Anyways, it's not with this one. So AIT is avoidant restrictive food intake disorder. And so this is like an avoidance or restriction of food intake that's separate from anorexia. I. Where it separates is there's different kinds of subtypes in that it is an avoidance of food, but [00:27:00] not related to body weight or any sort of body dysmorphia.

There's a couple of subtypes, like you have a general medical condition that kind of makes it difficult to eat, or just like a general food aversion. Like you'll see little kids who are like, I don't really feel like eating. Mm-hmm. Or it can happen after like a post-traumatic, uh, feeding disorder. Like they threw up, they were in the hospital, they had to get an NG tube and it was really hard.

And then they're just kind of aversive to eating. And then you can also have like a sensory food aversion. So like, I only like. You know, this kind of crunchy food. Mm-hmm. Um, Chicky nuggets. Yeah. Chicky nuggets and french fries and Lucky Charms cookies. They always 

Preston: beat Theit allegations.

Dr. Helen Liljenwall: Um, and oftentimes these patients will like really hyperfocus on. Like high calorie foods, which kind of distinguishes it from anorexia because it's like these, you know, either small [00:28:00] amounts or like very specific type of foods that actually have like pretty decent amount of calories in them. But oftentimes, so to qualify for arfid, you have to have either 

Margaret: to qualify for it, the Boston, to qualify to meet this diagnostic 

Dr. Helen Liljenwall: criteria.

You have to, it's not funny. Sorry. It's really not funny. It's very dark. Anyways, you have to either be dependent on some sort of like external feeding mechanism, like a G-tube and G or have like failure to thrive or significant nutritional deficiencies. So I think what's interesting in talking to parents about this is it's like a step further than a picky eater, right?

Preston: Mm-hmm. 

Dr. Helen Liljenwall: A pick eater will be like, you know, like, I don't like.

It scurvy, 

Margaret: but that's fine. 

Dr. Helen Liljenwall: You're actually, he won't get scurvy. You can eat broccoli. My brother looked this up when you were younger. Um,[00:29:00] 

James. Um, he eats fruit now though. Sometimes James, 

Margaret: you a long, 

Dr. Helen Liljenwall: um, but like. It's not just like normal picky eating, like, you know, I don't like this particular kind of food. It's like they will have like this intense anxiety with food and, you know, not to jump to treatment already, but it like, you work on like a, like a fear hierarchy almost in the same way that you would like a CBT exposure hierarchy to work on exposing to new foods.

Preston: So you mentioned that sensory issues can be a part of this. Mm-hmm. And one of the first things that came to mind was autism spectrum disorders. Yeah. Is this something that's seen as like comorbid with autism a lot? 

Dr. Helen Liljenwall: Yes. Yes. Definitely. Very comorbid. It often kind of goes hand in hand. 

Preston: And then, I guess, is this something you also see on medical floors more often as well?

I, I guess I'm just picturing someone that maybe they have, um, gastroparesis or something. Or like some [00:30:00] sort of like oph, esophageal paid, and every time they eat they are like given all these discomforting feelings or, or a lot of anguish. So I had, imagine I'd probably try to avoid eating after that. 

Dr. Helen Liljenwall: Yeah, I think that that kind of gets at like the, the comorbid medical condition that gets in the way of eating.

I will say on the gastroparesis thing, this is like my soap box. Maggie for it. Shaking it. I know what it's, it's that if you don't eat, you get gastroparesis. So like anytime someone is like, oh, we need a, like a study to see if they have gastroparesis and like, this patient hasn't been eating. I'm like, well, they probably have gastroparesis.

Like I could have told you that. 

Preston: Like a plain sound in sky kind of study where 

Dr. Helen Liljenwall: Yeah, like you're 

Preston: just gonna find what you know. 

Dr. Helen Liljenwall: Yeah. And you know, they say like, yeah, gastroparesis causes discomfort. Mm-hmm. And when you haven't eaten for a while, you're gonna have discomfort. So sometimes I don't even get the gastroparesis [00:31:00] study and I'm like, it could just be that you're just not used to eating.

And the way that you treat gastroparesis is by getting people to eat. So sometimes a little 

Margaret: Cipro Hep toine. Yeah. 

Dr. Helen Liljenwall: Cipro, 

Margaret: hept, toine. Sometimes all of that is a treat, can help or they can hate it, one or the other. Mm-hmm. This is my, I've been Preston and I've been mad about this since fourth year of med school, when I read a paper from my same mentor about this, and it was like, how long does it take for kids to get asked about eating disorders?

This is like a decade ago, and this paper came out, so I don't think this is true anymore, but it was like four like. Workup of uncertain abdominal pain and like chronic like constipation, diarrhea, whatever, like in younger kids or like young adults. And it was like the entire point of the paper was like, we need to ask earlier about eating disorders because it's like not being asked about.

And they go through these massive workups, which then also create, um. I mean beyond cost and like possible side effects. They also create further time before the eating disorder is [00:32:00] diagnosed, as well as creating like a medicalizing identity, which can be very, uh, I've found at least Helen, I'm curious your thoughts on this.

The identified patient? Yeah. 

Dr. Helen Liljenwall: Yeah. I think it can be unhelpful. And then it also adds this like hidden bias of like, oh, well it's just an eating disorder. Um. And then you are like, okay, well, like it's, it's like super serious. We also have treatments for it too. Mm-hmm. And it's not, and 

Preston: it's the cause of all these other medical problems that, 

Dr. Helen Liljenwall: that the work of is for.

Preston: Yeah. 

Dr. Helen Liljenwall: Like you're looking for one universal diagnosis, and then it's like, like they have an eating disorder, that's the universal diagnosis. Like, they don't have like gastroparesis, constipation, dah, dah, dah, dah. Like, yeah. It's, it is actually the universal one and talking to a psychiatrist is, is also talking to a doctor, which is my other soapbox.

Okay. Controversial. Controversial. 

Margaret: Hold on. [00:33:00] 

Um, is there anything else before we go into examples? I actually might make up a couple other ones that aren't media ones, but before we go into examples, anything else you wanna add about like common mix ups between diagnoses, Helen. 

Dr. Helen Liljenwall: Um, I think just kind of what I highlighted before in that like, you know, you can like oscillate between diagnoses.

Mm-hmm. And so, you know, like it's important to kind of keep asking and kind of keep looking at what's kind of in front of you because while some of the treatment is. The same for some of these, like some of the treatments are, are different as well, um, for the different diagnoses. 

Preston: So maybe this is more of a, like a personal question, but, um, have you ever like come across it being necessarily damaging but reinforcing to parts of the disorder in the way you screen for them?

And, and what I mean by that is like I've asked [00:34:00] someone. I was concerned that I had an eating disorder. I was like, have you ever used laxatives to induce weight loss or misused like diuretics or taking caffeine to suppress your appetite? And they were like, caffeine can suppress your appetite. And I was like, uh.

No, no, I can't. And they're like, they're like, dang, you could do that. And they're like, oh. And, and then she's like, I never thought of the laxative thing either. Thanks. And I'm like, no, excuse me. Hypotheticals. Whatcha talking about fact ler com 

Dr. Helen Liljenwall: are, you're just creating like patience for yourself. You're like, I am just gonna be a money bank at the end of it.

Yeah. 

Preston: I'm like, I'll see myself out. And like I'm saying this in jest, but like have you ever come across like situations like this or is this like a pressing unique issue? 

Dr. Helen Liljenwall: No. So yes and no. I think, I think screening for eating disorders, so funny enough, I was like talking about it this week that like I.

You know it's not taught in residency really, [00:35:00] like it's kind of a checkbox when we do an HPI that you're like any eating disorder. And then Julie, hey, do you think you're gross? Any ptsd, any psychosis, any eating disorders? Curious, can I just fill out my Epic smart block? Are you delusional by 

Preston: chance? No.

Okay, good. Moving on. Are you having hallucinations? 

Dr. Helen Liljenwall: But like, we don't really talk about like, you know, like the scoff, which is a validated eating disorder screener. Like, you know, you know, asking about like, what's your relationship with food and things like that. To your point of asking about, you know, something and giving a patient ideas.

What I'll say to that, it's the same thing that I say to medical students when they're asking about suicidality is no, you're not giving the patient an idea. Like by doing that. Right. Um, like. Have you ever had a suicidal thought? Oftentimes, you know, especially with kids, um, like, you know, it kind of, there's a lot of stigma with asking about suicidal ideation, [00:36:00] right?

Mm-hmm. There's a lot of stigma with asking about eating disorders, and then you kind of remove that barrier by asking them. I don't typically ask the specifics of laxative abuse, diuretic abuse, unless I'm doing it. Did you know you laxative by yourself? 

Margaret: Did you know you hide in a bottle under. 

Preston: Yeah, there like it could add way more specifics to that.

It's like, have you ever like used your sister's name to go into the pharmacy and order, order L damp and under her name and then take like two pills, pills, calls in your own morning, don't own. 

Margaret: Do you ever run so long that it hurts that you keep run? 

Dr. Helen Liljenwall: No, I typically ask that at the intakes though. And sometimes I'm like surprised because like, you know, like PA patients will be doing stuff that like, you know, they just wouldn't have kind of said unless you explicitly ask it.

So I think with that, yes. And then also, you know, when I see it in an outpatient basis from like an adult standpoint, I would just kind of ask [00:37:00] about like relationship with food and you know, do you feel like you have an eating disorder? And oftentimes even that question. Kind of opened up like, oh, actually, you know, I have X, Y, Z relationship with food.

And you know what I will say too, um, which I think is important to add, is it's entirely possible to have disordered eating behaviors, disordered eating thoughts that don't qualify for an eating disorder. Those are actually super common. Mm-hmm. I think it's something like a quarter of adolescents have some sort of disordered eating behavior or thoughts at some point in their adolescence.

[music]: You know, 

Dr. Helen Liljenwall: with diet culture, and, you know, the way that we talk about talking, female body dissatisfaction. Yeah. I mean, the way that we talk about food and eating in society in itself, like kind of lends itself to disordered eating behavior or like, you know, just unhappy thoughts about your body. 

Margaret: I, I wanna mention here as well that there is a separate category [00:38:00] for, um, like not needing disorders because you're not doing the behavior, but like body dysmorphic disorder, which also has subtypes within it.

And basically it's like the body dissatisfaction, preoccupations, all those things. Um mm-hmm. For. Hours a day get disrupting function. But that actually has a subtype that includes, I think, the rise we're seeing in young men with eating disorders. Um, we're seeing it in the body dysmorphia and the eating disorder world in terms of like preoccupation with like muscle building.

Um, so I thought found that interesting when I was reading about body dysmorphia like a few weeks ago for. A different podcast that I was not talking about this. I'll take 

Preston: it from here, Margaret. 

Margaret: Yeah. Live from, 

Preston: so actually lots of men can have muscle dysphoria. It's very common. I I've never suffered from it myself.

So at ease, everyone, um, about one in 10 men will use anabolic steroids at some point in their lifetime. One 

Margaret: in 10. 

Preston: One in 10. That's internationally. Yeah. [00:39:00] It's crazy. 'cause you, you have to think that a majority of the people that use anabolic steroids aren't actually bodybuilders. There are people that are hoping to look a certain way because they're unhappy with the way their body looks.

Margaret: One in 10 is so common. 

Preston: Yeah. And, and what's wild is that now that I started talking about it with like my bro friends, I guess. So it's like people will be like, they'll say like, yeah, I'm on test, is like kind of how they phrase it. Like people won't say like, yeah, I take anabolic steroids. Everybody knows a guy who knows a guy who goes to some men's health clinic where they have borderline low testosterone, and then they just prescribe them like transitioning level amounts of these hormones to treat like body dysmorphia functionally or muscle dysmorphia, and then it snowballs into another type of like eating and exercise disorder 

Margaret: and hormonal.

It's a really 

Preston: fascinating subculture. 

Margaret: Wow, that's so much more common. I knew it was like on the rise, but one in 10 is That's, [00:40:00] that's a, yeah. That's a lot of dudes out here fighting. Yeah, dude. Yeah. Fighting the demons. 

Preston: Flip, flip a coin in a public bus. A couple of 'em. And taking it. 

Margaret: Well, we will, we are planning to do an episode actually on this later.

Yes. This season. Stay tuned. Yeah. Stay, stay tuned. I'll tune in. Stay tuned for the testosterone episode. Um, 

Preston: okay. My, my soapbox is over. Thank you for listening. 

Margaret: Are you ready? Actually, I think we might get our acting skills out. Okay. Here's my thought, Helen, you're the doctor. Preston's your med student. Okay.

Um, I'll be a patient with an eating disorder and I think it would be helpful, I think often more than like describing these, this can be better and also gets, sometimes we do these and it's like funny sometimes they're very serious, but I think that this can be more illustrative. For our folks listening of how you would approach this kind of patient.

So I'll give you a, like brief vignette. All right. Um, maybe you can have a, do you want Preston, do you [00:41:00] wanna start the interview as a med student or should we just let Helen entirely take it? 

Preston: Uh, I can start it, I can do my best med student impression. 

Margaret: Okay. Um, so the vignette that you see on the front door, if this is an osce, um, you are walking in and it is a 17-year-old female, uh, who is presenting to.

Psychiatry after being seen by her pediatrician with, um, falling off of her growth curve. 

Her BMI is 18, uh, she is five to 95. Pounds. Let say maybe that BI 

might be wrong. I might have not calculated that right in my mind, but sure. Her weight is relatively in the low range, but not technically below 17.5.

Um, the pediatrician has referred her to you. Um, unfortunately because of child Psychiatry's weight list, it is six months later she is coming [00:42:00] into your outpatient office where you do not have scales or anyone doing vitals. Uh, and she has not seen the pediatrician since those six months. She's coming in to see you because she's been feeling anxious.

Preston: I, I can hardly feel myself getting anxious listening to vignette because, sorry, this, no, as, as far as like demographics that Preston does well with the 17-year-old girl with a eating disorder is like, that's, that's my hard mode, I guess I would say. Like I, I do really well with old people, slam dunk with old people.

Um, but yeah, it was funny. No, your strengths. Yeah, we always like joke about like, you know, who can play, play to what, um, demographic and the adolescent eating sort of female is always a challenge. So, um, I guess I, I'm coming into the room. Hey, uh, Preston, I'm nice meet you. Dr. Helen, [00:43:00] Dr. L. Continue. Doc, this is, sorry.

This is Dr. Dr. L one. We just, we just met earlier and she like, literally just gave me a, a rushed orientation now and then told, threw me into this conversation anyway, so I, I hear you're, uh, kind of anxious. What brings you in today? 

Margaret: Well, my mom told me that if I wanted to go on the trip this summer with my friend's family, I had to come see you guys because my pediatrician was worried or something.

Like, I mean, I, I'm anxious, but like, who's not anxious right now? 

Preston: Okay. Yeah. There, I mean, there's a lot of things to be worried about. What, what kind of things are you anxious about? 

Margaret: I mean, like the world, I know if you're paying attention, but. Not great. I'm anxious about like normal stuff like school. 

Preston: Hmm.

Margaret: Um, and I don't know, I guess I'm anxious about, I know they told you that like my, like weight was too low or something. So I guess I'm anxious about that because I just like don't get why it's a big deal. 

Preston: Hmm. [00:44:00] So, so to you, you don't think it's a problem at all? 

Margaret: I don't think my weight's a problem. No. I don't think my weight's a problem.

Preston: Gotcha. What does your mom think? I 

Margaret: mean, my mom, well, like what does she think about my body or what does she think about her body? Because she has one set of rules for her and one set of rules for me. Like she's all the time talking about how she like needs to stop eating this, that and the other. But for me, she's like, you're losing too much weight now.

But like, it wasn't a pro, it's not a problem for her. So why? Like, we have the same rules, so I don't get why it's a big deal. Gotcha. 

Preston: So So your mom's acting hypocritical? 

Margaret: Yeah, she's acting hypocritical. 

Preston: Okay. What rules have she set out for you? 

Margaret: Well, she doesn't set any rules out for me, but like her rules for herself are like, she can't have any desserts and there can't be desserts in the house, and she can't have any processed foods and she has to have all these clean foods, and she only can have like no seed oils.

And like I follow those rules and like I just care about my health, so I don't get why She's like, you need to go to a fricking psychiatrist just to like talk about the same thing that she does. Like why is she not here with, like, why isn't she here with me [00:45:00] right now? Mm-hmm. Why am I the one on trial?

Preston: Yeah. Uh, well, I would like to assure you, this is not a trial. We're just trying to help out and, and, you know, since we're both meeting each other, we can kind of try to figure out the best way to get out of this. Um, I know you mentioned that you, you're anxious and you want your body to look a certain way.

What would your ideal body look like? I said, I was anxious about my weight. Oh, I'm sorry. Your weight. Well, what's your ideal weight? Sorry, Resta. 

Dr. Helen Liljenwall: That was, that was mean, Maggie. That's how they would react though. That's how a lot of patients would react. Yeah. No, no, 

Preston: she's right. Like this is very accurate. 

Dr. Helen Liljenwall: I know.

I'm fine with my body. Like, I mean, who really like, likes their body? 

Preston: Um, I mean, I, I like my body. I think a lot of people do. 

Dr. Helen Liljenwall: Okay, well, you're like a guy, so, 

Preston: yeah. That, that's true. And, and I can only imagine. Or only begin to imagine what it's like dealing with your mom and I guess if, if this weight's a concern for you, just just so I kind of have an idea of where we're at, what is the weight you're hoping to [00:46:00] achieve or, or hoping to not achieve?

Dr. Helen Liljenwall: I 

Margaret: mean, I kind of just wanna stay where 

I'm at. I was like gaining weight a year ago and I run track and cross country and like. My coaches are kind of like, don't gain weight, and so I lost it and I stopped gaining weight and I'm like, fine. With where I am now, I could probably lose a couple more pounds and that would probably be better for my running.

Yeah, 

Preston: you seem like a really talented person. 

Margaret: You just 

met me. 

Preston: Well, I know, and I can already see that you're running track, you're doing two seasoned sports, you're doing well in school. You're worrying about all the things that you should worry about. That's, that's impressive. And, and not a lot of people your age are doing those things.

Margaret: I mean, all my friends are, 

Preston: but, well, we, we surround ourselves with like-minded people. 

Margaret: Yeah. I like care about running and that's why I'm also frustrated that this is like mm-hmm. I have to, like, something's wrong. Like [00:47:00] it, I've been running faster 

Preston: mm-hmm. Since I lost 

Margaret: the weight. So like, have your friends 

Preston: ever made comments about your weight?

Margaret: I mean, like, one of my best friends is like, not as, I'm not as close to her anymore. 'cause she would always tell me she was worried about. I was like losing weight. 

[music]: Hmm. 

Margaret: But she doesn't like do any sports, so she doesn't get it. And like, bless. See she doesn't like look like me. Like she is like bigger, but she's like bigger in a way that like guys, like in our school, like I'm not, I wonder what sorts of things you're doing to lose weight.

I mean, I started running more, but then I, I like, I'm kind of worried 'cause I can't run more because I like think I have a stress fracture now. Mm-hmm. And. I'm supposed to start training more for cross country in the fall in like a month, and I'm like kind of worried that if I keep running as much, I'm gonna worsen the stress fractures.

Dr. Helen Liljenwall: Okay. So you're running, is there anything else that you did after your track coaches kind of talked to you? Like, 

Margaret: I don't use any like supplements [00:48:00] or anything, but I'll like drink a bunch of like coffee and like caffeine and stuff to try and like make myself feel full. And like try to, like I heard like intermittent fasting is good for you.

So I like try to do that and like eat really, like I saw this like TikTok, that was like, if you eat food that's like a lot of volume, but it's like not a lot of calories and that's like a good way to stay, like skinny. Um. Mm-hmm. So I do that, like I'll have like a massive thing of like kale and like, that's the only thing I'll eat for 

lunch.

Preston: How many calories are in that kale? 

Margaret: Um. I think there's like 241 per serving. 

Preston: Oh, 

that, that's pretty accurate. Is counting calories something you do often? 

Margaret: I mean, I, it's just something I've done for the last couple years. My mom taught me to count calories. 

Preston: Gotcha. When's the last time you think you went a day without counting calories?[00:49:00] 

Margaret: I like can't turn it off. 

Like I can't look at, I like just, I know. I don't know how to not like, I like look at what I'm eating and I can't, like, it's like it automatically I can calculate it. 

Preston: Mm-hmm. You've just done it so many times that even if you do it consciously or subconsciously, it's there. 

Margaret: Yeah.

Like, I like that friend I mentioned like we went to like the, like the last time we hung out it was her birthday and she like got so mad at me 'cause like I wouldn't eat any of her birthday cake when we were out with her family. And like, I just got weird and like, I just, I couldn't do it. Like, I knew how many calories were in it and I like, I just.

I couldn't do it. 

Preston: That was, that was good Margaret. Very, that felt really realistic. 

Margaret: Yeah. Let's, how did that feel? And then we can talk a little bit about what she's presenting and like the details. Um, what did that feel like for you, Preston? 

Preston: Um, to be honest, like it, it felt like I was back in clinic the way, and I think even you were probably [00:50:00] nicer and like more forthcoming than a lot of like other patients I've had.

Mm-hmm. To a lot of my questions like, do your friends say anything you're concerned about? I think I was almost expecting you to say, I don't know, oh, how many calories are in kale? I don't know. Have you ever counted calories? I don't know. Like I, that's, that's almost like what I anticipate the conversation to go like, just, just without this sense of rapport being shut down immediately.

So I was kinda like, wow, she's given us a lot. Was my, my initial, even though you were kinda like nitpicking me about like my reflections, these semantic details. Um, I could, I really felt and understood how egos the disorder was for you. Yeah. Um, I thought that was conveyed well and I, I think it came through in the different, like layers of our questioning.

Dr. Helen Liljenwall: I agree with Preston. I also think Preston needed a good job of kind of soliciting some of the information that you need to, but asking it in a way that the patient's gonna be receptive of like in a sneaky [00:51:00] way. 

Preston: I'm a sneaky guy. That's what I do. 

Dr. Helen Liljenwall: At first, like when you asked how many calories was in kale, I was like, Ooh.

And then when Maggie answered, I was like, yeah, actually that was a good question because like, to be fair, like the counting calories is like all day, like. They know how many calories is them.

Margaret: Yeah. I feel like Preston, I think you did a good job of like not rising to the bait. I feel like sometimes with patients with eating disorders and patient like an adolescent patients, right, there can be this, like we, I don't trust you. You're an adult who's gonna take this eating disorder away from me.

You're also just like an adult. Like what do you know? Mm-hmm. And the calorie counting point, I think is one that is important and part of why I answered it, which is like the, like are you doing this kind of the automaticity of some eating disorder behaviors? Uh, Helen, I wonder if you had thoughts 

on interactions with family [00:52:00] dynamics?

Dr. Helen Liljenwall: Yeah, I think, you know, uh, it's interesting you talked about like the. Expectation for mom, expectation for kid. 'cause with a lot of pediatric eating disorders, sometimes we'll kind of see like, almost like this feeling of like justice, like this is unfair, that like you have these expectations for me, yet other people have other expectations to which the answer is like, well, you know, other people have other body types and other people have other things going on.

Right. You know? Um, so the rule of. You know, you needing to be within like a healthy weight range is is different, right? Um, so I think that's interesting.

Preston: Well, thank you so much for listening today. I know this is a halfway point and today we had a Margaret episode. We're doing [00:53:00] this new dynamic. If you haven't caught on that, Margaret's gonna be in charge of an episode and Preston will be in charge of an episode. And this is not producer sanctioned, but I think we should start to have a bit of a voting um, poll going on.

I think we're gonna do that. Who prefers pre I? Good. This like the podcast 

Margaret: version of like sharing a room with your sibling and like drawing a line down the middle with tape and being like, that's your 

Preston: side. 

Yeah, exactly. So yeah, I mean, it's fun for me to be along for the ride and I think we'll kind of start to see how we have our dynamic and then our own episodes begin to get their own personalities.

Mm-hmm. But outside of that, um, let us know how you like the show. Let us know what you think about any of our topics. If you saw us a PA. I was happy to see you. Thank you so much for your questions on the panel. That's actually my first time going to a conference. It was my first time talking on a panel and feeling like I was official in any sort of capacity around social media, and y'all made it surreal and it was a huge honor to be there.

So for [00:54:00] everyone who I saw and everyone who I didn't see, um, thank you so much for supporting the podcast. If you want to come chat with us more, you can find us on the Human Content Podcast, family on Instagram and TikTok at Human Content Pods. We also have our Instagram How to Be Patient Pod. You can't miss it.

It's the, the yellow brain with the glasses on it. We're almost up. To 2000 followers on Instagram. It's like Margaret and i's shared Neopet, so please help that thing grow. Yeah, it's 

Margaret: we're siblings. Don't let, can we have a child? Let star please. 

Preston: This is our chance at co-parenting. Shout out to everyone who left questions about our eating disorders episode.

We're gonna get into those in the second part of that and become the whole second half of that episode is gonna be focused on answering those questions. We, we go into a lot of them, um, pretty in depth and so I, I hope you'll appreciate that. If you wanna see the full video episodes, they're on my YouTube channel at.

It's Preo. If you'll listen to 'em, you can find 'em just about anywhere from Apple Podcasts to Spotify. Thanks again for listening. We're your host, Preston Roche and Margaret Duncan. Our executive producers are me, Preston, Roche, Margaret Duncan, will Flannery, Kristin Flannery, Aaron Corny, [00:55:00] Rob Goldman, and Shahnti Brooke, our editor engineers Jason tzo.

Our music is Bio Ma Reds v. To learn more about our program, disclaimer and ethics policy submission verification, licensing terms, and our HIPAA release terms, go to How to be patient pod.com or reach out to us at how to Be patient@humancontent.com with any questions or concerns. How to be patient is the human content production.

How to.

Thank you for watching. If you wanna see more of us or if you wanna see, this is lilac. She's my cat. She's gonna be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac Point to the other episodes. Lilac doesn't know what the internet is, but I swear they're there. They, they probably exist for real.

But in the meantime, I'm just gonna pet lilac and then [00:56:00] I'm gonna go dance in the background.