Eating Disorders for Psychiatrists: Part 2

Dr. Helen Liljenwall: [00:00:00] I'm not expecting body positivity, but like body neutrality would like kind of, at a minimum is something to strive for and that you kind of recognize like your body's moving, it's doing things like how great is that?

Margaret: Hey guys. Welcome back to How To Be Patient. We are doing part two today of the Eating Disorder episode. We had part one last time, and we luckily, and unfortunately for her, still have our guest with us. Actually, can I do this 

Preston: intro? Yeah. I just feel like it's been a while since a man's gotten to talk on this podcast, 

Margaret: and that's, and you always say that 

Preston: I'm, I'm over here with a, with a mic and headphones and I'm just suffering in silence.

Margaret: I don't think I'm with a mic and headphones in a podcast suffered in silence. White, I'm Whites Voice was heard on this topic. Silence one time. I'd like to see you suffer in silence a little more.

Alright, let's get into it. 

Preston: Versus listening quietly, 

Margaret: 100 [00:01:00] men, as I said before, the episode versus active listening 

Preston: skills. Okay, but, but I did. Actively listen and I will you tell you the things that I listened to during the last podcast? So we, so in the first part, we kind of went through some of the different subtypes of anorexia and also the different types of eating disorders.

So we, we went in and out of anorexia nervosa, bulimia, binge eating disorder. And then even like the nuances between unspecified and other specified disorders are s fed and os fed if you're feeling fancy. And then. We kind of tried to apply some of our skills and I got to luckily be this med student interviewing a very challenging patient that was moderate role-playing as a, a teenage girl with an eating disorder on a cross country team.

And we're gonna start out this episode, kind of unpacking what we went through in that setting. And then we're gonna roll into some more, um, general discussion about where the field is at within eating disorders. And we're gonna get to all the questions that you guys asked us about eating disorders and kind of let that guide the rest of the [00:02:00] discussion.

Margaret: All right, let's go into it.

Preston: So another thing that I, um, really liked that you did, uh, you kind of played into this like almost UWorld style vignette with the Crest country and the almost like obsessive compulsive personality organization around school and, and friendships and other things is, um. The, bring up the stress fracture too.

So you are already getting into sequelae from this disorder. It kinda made me think of the, the female athlete triad. 

Mm-hmm. Where 

you, you now have suppression of that, like hypo pituitary, um, ovarian access and you're not producing estrogen anymore. You. So I think the other thing that was kind of slowly gonna get towards that we didn't do, but would be to ask about menstruation.

Mm-hmm. Which, you know, as you know, coming from me is always the best, but I.[00:03:00] 

I'm like, I'm like famously. Yeah. The best person to ask you about menstruation is the, the mid twenties guy with a mustache and a and a beard who looks like he goes to the gym and probably had crazy. This he loyal before was so handsome. Yeah. I'm like, what's up? What? Ask 

Margaret: that. 

Preston: Any, any good menzie lady later lately?

Bro, please, 

Margaret: ladies, listen up. 

Preston: You got a heavy flow or a light flow? Wind. Whatever's wind.

But, um, it's funny, we, we, I was a, uh, cross country track guy in college and we got that talk a lot. Mm-hmm. Um, and I remember there were a lot of females on our team that would almost have a similar flippant response. Like they would go into the trainer with these stress fractures and would have amenorrhea and have like signs of anorexia.

And so like that. This like prototype of a person you're describing like, like I know people in real life that like the exact person is like coming up [00:04:00] that went, went through a lot of these issues. Mm-hmm. And, and felt the same way. 

Margaret: Yeah, I mean I think there's also this stuff of like sport and identity, which I'm in this like sub fellowship at my residency that's like a sports psychiatry.

You read a bunch of articles and stuff and do a project, and one of the things we've talked a lot about is like reds, which is like relative energy deficiency syndrome, which shows up and with the like female athlete triad, but even without eating disorder behaviors or purposeful things, just like underestimation of energy needs for female athletes.

Preston: Mm-hmm. Sorry to clarify. I, oh God, I might even get this wrong. What? What are the three tiers of the female athlete triad 

Margaret: Tri? Well, I think there's three factors and it's like, yeah, easier bone breaks, a amenorrhea. 

What is the third one? 

Preston: Is it restrictive eating? 

Dr. Helen Liljenwall: No, I think it's suppression of like, I think it's like actual, well, with the amenorrhea, I thought it was like suppression of puberty.

Margaret: Yeah, like hormonal changes. [00:05:00] We'll quote me on that. We'll, we'll see. We need to come, we'll do a, that another sports psychiatry. I need to review step, step two material. Yeah, but I mean it's also quality basically of like an eating disorder in a lot of ways. It's like it's, oh, it's 

Preston: low energy availability, menstrual dysfunction and low bone mineral density.

Oh, so it's 

Margaret: the thing that you're doing and then two symptoms, like, it's like, mm-hmm. Okay. 

Preston: Got it. Yeah. 

Margaret: Um, what are the physical, one of the things we didn't get to is like, what are the physical things you guys would ask about for this patient presenting to your clinic? 

Preston: I, I, I'm not sure what you mean by physical, but like, I think I'd be looking for things like Russell sign, which, um, I don't, I've never seen it in person, but that's like a classic, you know, UWorld thing where you have like, um, bruising or excoriations on the back of your knuckles.

Uh, I'd be looking for things like lacuna, which are those like really thin hairs that are signs of like nutritional deficiency. Um, I guess one thing, am I, am I like totally off here about what you're No, you're not. You're not, you're 

Dr. Helen Liljenwall: not totally off. But here are the things that I would ask maybe. Okay. [00:06:00] Um, amenorrhea, cold intolerance, like standing up and being dizzy and syncope, things like that.

Um. Because they're not gonna know if like they have Tufts of pair. 

Preston: Well, I guess I was, I was pointing out like what I would look for Oh yeah, yeah. In a physical exam. Physical exam, rather than the review of systems. So I was kind of skipping a step there. Yeah. I guess constipation could probably be another one.

Mm-hmm. Yeah. 

Margaret: I guess one of the things, Helen, I'm interested in, as you know, um, and if people wanna resource on on this, um, both of us are, I think, kind of citing not just the primary literature, but the a PA guide that came out on eating disorder treatment in 2023, which is a free PDF and resource for a lot of, um, these clinical things we're discussing.

But is someone I, I come to you an outpatient, my BMI is hedging. Let's say I'm still losing weight and you actually do get a weight there and my BMI is now 17 and I'm not doing any approaching behaviors. I am very [00:07:00] much act actively still restricting. How do you think about whether someone can stay? I.

Outpatient or whether they are becoming medically dangerous enough that they need to have an emergent workup in the ED or check in. I don't think that this person's necessarily there, but I think I also haven't given you enough information for you to 

Dr. Helen Liljenwall: know, honestly, if they went from 18 to 17, that's the emergency room for me.

Mm-hmm. But you're looking for like the physical signs, so like. You know, like blood pressure labs, like, and you know, looking at the a PA guideline for who gets admitted, um, actually knew this very well. 'cause these were like a lot of the admission criteria that I was looking at for the, my own eating disorder pathway that I made.

1. But like, I would want a basic set of labs and with that as well, like looking at like your, um, renal function panel, but basic metabolic panel with a mag and a foss. Mm-hmm. Um, and, you know, A [00:08:00] CBC, um, EKG, things like that. Um, something to kind of also note with that is sometimes like the initial labs look normal because someone's been restricting for so long that they're not actually gonna refeed.

Which is what we're looking for, right? Like an alteration with the K mag and Foss. And 

Preston: for people that aren't as versed in medicine, can you explain why CAG and FOSS are so important in Refeeding syndrome? Yes. Or what even is Refeeding syndrome? 

Dr. Helen Liljenwall: Yes, I can. So we have our cells in the body, right? And imagine they're like, 

Preston: I'm sad.

Dr. Helen Liljenwall: Well, I mean, this is not my first time explaining this. 

Margaret: We're not her first cell rodeo. We have, 

Dr. Helen Liljenwall: so we have cells in our body. And imagine that you're like, that your cell is like a fish in a salt water tank. Right. Like we got osmosis going on and so if we start taking the salt away from the water, the fish is gonna start like getting smaller and [00:09:00] smaller and the water is, or like the well will go out.

You taking salt away. I guess more salt will the same in the tank, 

Preston: but the fish loses salt. 

Dr. Helen Liljenwall: The fish will lose some salt. Right? So then like over time, like similarly, your cells, if you're not getting enough nutrition, like we're losing a lot of the electrolytes that we need to function, especially phosphate, right?

Because a TP you've gotta cut that, a TP and then, you know, powerhouse the 

Preston: cell, powerhouse the cell mitochondria. 

Dr. Helen Liljenwall: Um, that's usually where people kind of come back in, in my explanation. They're like, I got this powerhouse of the cell. They're like, yeah, totally. Um, and so. You know, you're depleted these electrolytes and then all of a sudden you start, um, you know, so your cells kind of shrunken down.

Then you start eating again and the cell's like, oh, like look at all these nutrients. Like I can start making all this energy. And then they start grabbing like all of those electrolytes. And so you can get severe electrolytes, [00:10:00] derangement, just be, if you, um, start like eating like really quickly. Um, and start increasing that energy intake.

Margaret: Okay. So similar to the osmosis part, um, is that there is, if someone is truly not eating a lot and suddenly they have a higher calorie intake, there can be an insulin surge that is like, oh, we finally have calories. Like, let's get these into cells. Let's get this move. And that brings a potassium shift, which having that potassium shift is part of, um.

As well as the magnesium and pho, like that change is part of something that can elicit, uh, cardiac rhythm changes due to the change in, um, electrolyte minerals, whatever. Mm-hmm. We won't. Cardiac risk during Refeeding syndrome. 

Preston: Particular, and, and I think it's one thing to say like, you know, acute cardiac risk of a risk of arrhythmias, but the, the takeaway for people who are less medically verse listening to this is that refit refeeding syndrome can be deadly.

Mm-hmm. And you can induce basically cardiac arrest by giving someone food too [00:11:00] quickly and having their electrolytes become messed up, 

Dr. Helen Liljenwall: which is why it's super important to have a dietician on the team. Yeah. Because also like. You know, there's a lot of literature about this and it used to be like we were really cautious with how, what, like the amount of calories we would start, start these patients on.

But we've actually realized you can actually start 'em pretty high, but it's better to kind of focus on like proteins and more like complex calories. Yes. Teens and aminos at the beginning. And then you can start to introduce more carbs. Um, 

Preston: BCAAs.

Margaret: I mean, you'll get a, a dry, uh, scoop of protein and yeah, there's just a 

Preston: GNC attached to the unit. 

Dr. Helen Liljenwall: I don't, I don't eat protein like you guys do, so I feel like I do. I'm trying to get protein scoops that you, I'm 

Margaret: trying to get you to care. Protein, 

Dr. Helen Liljenwall: I'll never scoop of protein. There's already evidence for 

Preston: creatine in refit.

Dr. Helen Liljenwall: I have no idea. That's not 

Preston: so [00:12:00] anyone has ever even looked into, because now I kind of like wanna look into that. 

Dr. Helen Liljenwall: I think, I mean, you, you get 'em to like a, you know, yeah. The, the car complex carbs pretty quickly and carbohydrates pretty quickly. And then also something I didn't talk about too, Maggie, is like low heart rate, super common, and.

Requires telemetry. 

Margaret: I think the other thing is like, again, depending on how long someone's had an eating disorder for, is that like if they're atrophied in the muscles in the rest of the body, they're also atrophied in the muscle of the heart sometimes meaning mm-hmm. Can be volume overloaded and that can be part of the refeeding in addition to arrhythmias of like swelling or heart failure due to multiple causes in terms of the derangement, electrolytes, and the heart muscle atrophy.

Dr. Helen Liljenwall: Which I think is important. You know, there's a lot of medical sequelae of specifically like anorexia and restrictive eating disorders, but, um, for like residents or medical professionals who are listening to this, like, do not give IV fluids, or if you [00:13:00] do give IV fluids, give them really cautiously, like PO is much better because you run a risk of cardiac overload.

If they're very volume depleted, their heart may not be able to pump as well as. Someone else, and then you kind of run the risk also, um, if they have a low albumin of third spacing and just do it cautiously. Oh yeah. Psychiatrist. The best advice ever for medical doctors too. I'm a doctor too, that's what I say.

Yeah. 

Preston: A gen search resident once told me, um, if you ever can always feed the gut, and I, I found it to be true in so many facets of medicine. 

Margaret: Mm-hmm. We had a bunch of other things that we wanted to talk about, and so I think this has been like a really good case discussion around some of the basics, um, as well as some of the other questions that we have gotten.

Um, I wanna talk a little bit about your work outside of individual patients, Helen. Yeah. Um, with, you mentioned the helping to implement a pathway for eating disorder care with, as we're [00:14:00] joking about like the medical part of this and the psychiatric and, you know, levels of care. In most places in the us um, including places with quite a lot of clinical access, there is not often a coherent continuum of care for eating disorders.

Kind of. I mean, I, you know what I think, I think it's partially because there's. Many domains that we are acutely worried about and no one is a master necessarily of all of 'em for these patients. And then also that we don't have treatments that make people better right away. And so we're still looking for excellent treatments.

We're still looking to make someone better permanently, and we don't yet have those. And so if you would talk a little bit about your work and the part of care in terms of like hospital admissions and what drove you to it. Yeah. 

Dr. Helen Liljenwall: Yeah, I think, you know, so in psychiatry training you work in peds and adults and you do a little bit of dabbling in your adult, um, residency and child.

And when I started my residency, I was on adolescent medicine unit and we just [00:15:00] rocked the eating disorders. We were taking care of these kids. They had got excellent care and you know. Um, I really felt like I had a handle on how to care for eating disorders. And then, you know, in child psychiatry they take care of eating disorders.

And then when I got to adult psychiatry, it was kind of, as you described, Maggie, like, it's kind of like hot potato. Like everyone's like, oh, they have an eating disorder, not me. Um, and like no one really kind of took ownership of these patients. And, um, what I found like working on the psychiatry cl service in particular was like.

Patients would come with these medical comorbidities that we were talking about. And then they wouldn't eat. Mm-hmm. Because like there wasn't actually like a structured plan for nutrition and a lot of times nutrition food was medicine. Like there was either behaviors that were interfering with eating or, um, you know, anorexia, like an actual diagnosis interfering.

Um, and so I kind of piggybacked on some work that a fellow was doing. She was [00:16:00] leaving, um, fellowship by the time that I was entering my second year of residency. And she had started. To try to create a pathway to treat adult patients with eating disorders or behaviors that are interfering with nutrition on the inpatient medical floors.

And it took off while I was there, um, and led the project. Part of it was we had a really good multidisciplinary team, like psychiatry, nursing, nutrition, psychology from the pediatrics hospitals, adolescent medicine from the pediatrics hospital. Um, critical care was involved, the medicine service because these patients were popping up all over the hospital and you know.

It kind of demonstrated to me like, first of all, like that this is a continuum of care. There's a lot of people who are involved and then also how much eating disorders kind of scare specialties or scare people. Like they see it and they're like, I don't really know how to do this. Um, when in [00:17:00] fact like, we do have treatments and we do know how to treat this.

Um, it's just kind of difficult. So that was kind of my, my story, but it got published. It's used now. So that was, 

Margaret: I've used it. I've used, like, y'all need to look at this. Um, yeah. Yeah. That's been my ex uh, like everyone gets involved when there's like an adult eating disorder patient because the ethics of it are so difficult because it's, yeah, it's difficult when it's a child, but when it's an adult and like.

I've had some of my like earlier residents when I'm like their backup PGY four. We'll talk about it later. Like where is this line? Especially if someone's in an underfed body acutely and we're saying food is medicine. There is this question of like capacity psychosis, like how rigid does this view need to be and out of line with reality for us to force food?

And that's an ongoing, uh. Difficult question. 

Dr. Helen Liljenwall: I think you're touching on something that's really important and it's really difficult because, [00:18:00] you know, we talked about the ego, syntonic nature of this disease and that you can, in the way that we evaluate capacity as psychiatrist, right? They love or any medical, any medical doctor can evaluate.

Okay? Apple bomb mentioned with apple bomb's criteria, right? Is like a, um. That their decision is aligned with like prior values, right? Well, when those values are distorted, how? It's not very easy to kind of like clinically recognize this and the disorder in itself, right? Not recognizing when you are medically ill from this disorder is in the definition of anorexia, so it gets really hard.

And then also kind of the practical nature of it is very difficult because you have to have some buy-in from the patient. Whether it be by getting family involved and, and getting a lot of other team members trying to find like their crux, like, you know, with this female athlete we were talking about before.

Like, okay, well how do we get [00:19:00] you to a place where you're not, you know, getting a stress fracture from running, like what is gonna be our hook and our buy-in? 

[music]: Mm-hmm. 

Dr. Helen Liljenwall: Um, and oftentimes like getting to them to recognize like how medically ill they are and what the nutrition will do for it. Um, it's not easy.

And it's, it's just, it's really complicated. 

Margaret: Preston, have you had experience with like adult inpatient eating disorder consults? 

Preston: Um, not particularly. Um, there's not a lot of. Anorexia that I've 

come across in San Antonio. Gotcha, gotcha. 

Margaret: Yeah, it's a, it's always 

a battle. It's a battle, 

Dr. Helen Liljenwall: not just patient. I mean, it's there.

I, I grew up in San Antonio, so very good. Um, 

Preston: at least not that we get called on in the hospital, I guess. 

Dr. Helen Liljenwall: Yeah. Yeah. And I think that's also part of it with the pathway is mm-hmm. We started educating all of these other services about eating disorders and suddenly we started seeing more [00:20:00] eating disorders.

Margaret: You're like, 

Dr. Helen Liljenwall: because people started asking about it them 

Margaret: and then people were like, I can do that. Like Preston mentioned earlier, they were like, 

Dr. Helen Liljenwall: I can suppress my appetite with Kathy. I should take 

Margaret: la my sister's la this. 

Dr. Helen Liljenwall: Um, because when you start screening for it, you start seeing it, right? Mm-hmm. And that was something that I kind of talked about as well with implementing the pathway is, you know, there's sometimes some resistance because like the, it's a lot of work to care for these patients.

And if you act like it's not there, then. They don't have it in cured, in cured mentality way. Right. You're like cured, like, oh, if this is, there's no nailed it issue with nutrition, like then they don't have an issue with nutrition. Um, but the capacity is is really interesting too. And the biggest difference between pediatrics and adults that I've found is like when you're a kid, like your parents are the end all be all.

And so it. In my mind it's, it's like a lot easier to get that buy-in, get that treatment and like the treatment for [00:21:00] anorexia in addition to the food. Uh, one of the best evidence-based treatments is, um, family-based therapy, working with parents and kids. Um, and then for anorexia, they try to kind of like delineate that to like relationship when you're older, but you really have to kind of lean on a lot of social supports, which is something that I don't know that adult psychiatry does as well as child psychiatry is getting the family involved.

Preston: You, you can't pick up on or find what you don't look for. 

Margaret: Mm-hmm. Mm-hmm. Yeah. And the screening question with it, I think it's also like where do we delineate normal behaviors or like, what's the normal amount for this to be disrupting? Especially if you look into like idio cultures within like different sports, different age groups, different even like parts of society of.

How much is it normal to care or track these like track calories or be restrictive or have more rigid food rules? Um, yeah. And was there [00:22:00] anything about the implementation process or designing it that surprised you? 

Dr. Helen Liljenwall: I think what surprised me, well, I guess. A couple things. One is if you have like a clinical pathway, if you have ways to kind of like outline for teams and for patients, like this is the rules, especially early on in treatment.

Mm-hmm. People do better with that. Like a lot of like psychiatry, cl they love to say is like managing distress of teams in addition to the patients. Mm-hmm. And when you have and liaison. I know they love to be like, that's the liaison part. 

Margaret: It, they do love to say that. 

Dr. Helen Liljenwall: And I'm like, I don't wanna have to manage another team's anxiety.

I wanna manage my own bad. Yeah. And, and so you having those structures and those roles, like, it seems like a lot of work at the beginning, but then it actually makes it more streamlined. Then also I kind of figured out like how awesome it is to just work in a multidisciplinary [00:23:00] team and be like, okay, like that is your wheelhouse and I trust you to complete that.

Especially at pediatric eating disorders, like I have my dieticians, I have my psychologists, I have my social workers, I have my school services people. I know that I can depend on them and nursing like to do kind of their own things within there and that they're the experts, like I don't have to be the expert in mm-hmm.

Nutrition. I don't need to know the amount of calories that they need to be getting in or the kinds of like breakdown of things, like I can trust that I can learn it and that they'll teach it to me and also like they're gonna be in charge of that wheelhouse. 

Margaret: I feel like that part is like both relieving but also so fun.

I've, I've found of working in eating disorders is like you get to be around a bunch of like smart people often mm-hmm. Who like know an entirely different way of how to help the patient than what the way you know how to help them. And I just think that's like fascinating. I mean, I mean, one of the, there is an eating disorder place that.

I had rotated out when I was in St. Louis that also has like a sport [00:24:00] program and they would have physical therapy come in and like talk about getting back to exercise for athletes. Um, so yeah, that's really great. I'm sure really helpful that you guys put that into place. We could use it probably more.

Hospitals, we are gonna take a quick break and we come back. We're gonna do questions we got 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 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: [00:25:00] 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 kic. 

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 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. So it, it's important just to, to keep it on your [00:26:00] 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.

Welcome back. We are going to speed run some questions. Uh. Knowing me, I won't do well at that, but we will try and be less nuanced and get three more questions we got asked. 

Preston: Perfect. What she means to say is, thank you for all of your thoughtful questions, and we're gonna answer them to the best of our ability 

Dr. Helen Liljenwall: thoroughly in a length, lengthy way.

Preston: Mm-hmm. 

Dr. Helen Liljenwall: Okay. 

Preston: Um, oh, here's one. How does an eating disorder affect someone's social life and social decisions? 

Dr. Helen Liljenwall: Okay. I was gonna say rapid fire with that one. You know, depending on the eating disorder. Um, but in like anorexia in particular, um, or [00:27:00] honestly a lot of them, like food kind of dominates your life and it's very self-centered and so you kind of can pull back from a lot of social interactions.

It's like almost like so. For lack of a better word, like selfish and personal that then like relating to other peers can kind of be really difficult. Um, and so kind of getting outta that shell and kind of focusing on external things is, is actually really helpful for recovery. 

Preston: Oh, one phrase that I've, I've heard is like, misery, misery may love company, but eating disorders love competition.

And it's like, it changes, it can change how you view other people in these settings. Mm-hmm. I was reading this book called, uh, life Without Ed. That's a great one. Mm-hmm. Yeah. So, so like Ed, ed since her eating disorder, but like he's personified kind of as this voice mm-hmm. Inside the character's head throughout the novel.

And one thing that like Ed would say to her is that while there's all these negative things and punishing things about, like how you, you, you're ugly and you're fat and you'll be terrible if you eat this. But you would also say positive things. Hmm. In like, um. [00:28:00] Malicious sense. Like, look at you, you only ate a potato for lunch, but all these, you know, fat asses next to you, they all had cake.

Mm-hmm. And you're, and you're better than them because of that. Or you get to get into an elevator and think I'm the skinniest person in this elevator. You know, they, therefore I'm better. Or something like that. So. So there are ways that the eating disorder can feed concepts about yourself that are.

Almost like unhealthy and, and, and maybe even a little grandiose, and maybe I'm probably using the wrong term. Mm-hmm. I can't think. Yeah, I guess, I guess it is grandiosity, um, that can also like affect who you choose to, to spend time with or hang out with. 

Margaret: Yeah. I mean, I think, but I agree with both of what you guys said.

I think also what we started with, that there's a cultural and identity part of eating and sharing food together That is. I think pretty intrinsic to being human. And so when we can't engage in those, and in the example I think I gave like the birthday cake one, we lose something embodied and something physical about connecting not just with ourselves [00:29:00] but with others around us because we can't do this kind of very old human thing.

Mm-hmm. Um, so I think that that. Impact, depending on how severe the eating disorder is. Severe meaning, not weight, but like how intense and frequently it's getting in the way can really disrupt a lot of life's, like sweetest kind of dear moments. Mm-hmm. 

Preston: The, like, the most human thing you can do is share food with another person.

Yeah. Like, like even in like movies when like, you're showing that like one person doesn't trust another, like, it's like, it's like a literary mechanism to like show. Trust and bonding. Like, here, I'll eat the cookie. Then you eat the cookie. Like, look at us sharing this moment. It's like, mm-hmm. It's like the most primal way in which humans have like built communities through food, and then that whole piece is ripped out of it.

Mm-hmm. 

Dr. Helen Liljenwall: Mm-hmm. Yeah. Yeah. It's, it's very intimate, like sharing meals and. Creates community. 

Margaret: Helen, I think you had picked a question. I'm ready for all 

Dr. Helen Liljenwall: of the questions. 

Preston: I've got another one then. Okay. Preston, you go. So what are your [00:30:00] thoughts on the term terminal anorexia? 

Margaret: Uh, this was from my sister's friend who's a psychologist, uh, from college.

Hi Lauren. Um, yeah, terminal anorexia. Helen, I want you to go for, 

Dr. Helen Liljenwall: I. To kind of put the term terminal anorexia into context with nuance. Thank you, Margaret. Maggie, um, is that we need to also talk about two other terms, seed and scene, which is severe and enduring eating disorder and severe and enduring anorexia nervosa.

So these are all kind of terms to describe kind of a persistent, prolonged protracted course of an eating disorder. And in order to qualify for qualify, I keep using this in order to kind of meet criteria. It's like a running competition in order to meet criteria for these diagnoses. People have tried to kind of.

Outline like what it means, but it's really hard. Like for severe and enduring anorexia nervosa eating disorder, I think it's like three years and you've failed two [00:31:00] treatments and like you're not getting better. And what it is is. Kind of talking about like at what point, um, you wanna weigh beneficence with non maleficence mm-hmm.

And patient autonomy in there too. And that, um, you know, part of anorexia is like having a certain weight goal and target weight and ideal body weight and. Like the positive way, not in the ideal body weight that like the disorder will have. Um, and getting better involves like getting back to that nutritional standpoint.

Um, and so that term terminal anorexia nervosa, um, kind of talks about when patients no longer kind of wanna go into treatment, it is too difficult for them and kind of having a conversation about how to potentially like, look to palliation as opposed to mm-hmm. Curative measures. There's a lot of discourse about this though, because what we do know [00:32:00] is if you don't set those expectations, especially early on, like patients also aren't gonna get better, right?

And so you want to both balance, like setting those expectations and setting, you know, like aiming for recovery while also weighing like, what is recovery doing for. For those patients and like, what does that look like? So, um, terminal anorexia nervosa was in an article by Joel Yeager who recently passed away.

Um, and was it kind of a way to kind of talk about that conversation? Yeah. 

Preston: And, and when you're talking about failing treatment or not wanting to go back to treatment or like it being distressing? Um, I think it's, it's hard kind of. What exactly like those circumstances are. And so, so to clarify this, these are places where someone is almost being force fed in a distressing amount, and then it's just like you want to go back and do, do this thing that you hate over and over and over again.

Dr. Helen Liljenwall: I [00:33:00] wonder if it might be helpful briefly to kind of touch on something I didn't touch on, which was the Minnesota starvation study. Like why go we actually are doing food as medicine. 'cause I feel like I say food as medicine and my patients sometimes may roll their eyes. Yeah, like that's cute. 

Preston: Yeah. I mean that could be a whole nother episode too.

Margaret: Let's talk about, I mean, and brief the Minnesota starvation study in brief. Is they did calorie restriction of like, I think 40%. It was like young, healthy, conscientious objectors, um, trying to figure out how to like avoid refeeding and go back into like adding calories after World War ii and they. Lost something like 30 to percent of their body weight per person.

And they functionally had to stop the study because people were like getting quite depressed. They were getting to the point of like obsessiveness with food almost solutions, and they were like. There was nothing else. Developing eating disorders, developing eating disorder, essentially. Disorders. Yeah.

And so from the starvation was a mental status change observed enough to the [00:34:00] extent that even in the forties they were like, we can't ethically continue, which says a lot 

Dr. Helen Liljenwall: because they agreed to this study in the first place. Yeah. 

Preston: Because like down the street, they're doing a Stanford prison experiment and they're just like, this, just Minnesota was like, let's 

Margaret: topic.

This is 

Preston: too much. 

Margaret: But point being is what like food is, medicine is like, there is an alteration in an acutely starved and prolonged starved brain to the extent where we say an eating disorder recovery, that it takes being recovered for about a year for the brain to be how it was in some ways before the prolonged.

Malnutrition. Mm-hmm. 

Preston: Yeah. I, I may be misremembering this, but like, I think they did IQ testing on them and like they were observing like almost like linear, like dose dependent drops in their iq or like their cognitive rigidity as their body was going down. 

Dr. Helen Liljenwall: Yeah. And the rigidity. Yeah. And alexathymia.

Yeah. 

Margaret: Yeah. I think that there's also the systems [00:35:00] question with this, which Helen, I have about offline. How would this be picked up and how do we pick it up as a diagnosis without having it fall into the wrong hands? For example, getting people coverage for eating disorder treatment for the amount of time they need, it is extremely difficult and almost impossible, even on good insurance.

And so if this term exists. Where does that line become? What does that mean when someone's acutely in the underfed state where their brain can't necessarily see a light at the end of the tunnel? Like if that's an option. So I think there's a large systems question with this as well, part of the controversial nature of this.

But also there are people who have been in good treatment like evidence-based treatment for decades and are, are in a lot of pain and are are not better. And so I think there's a lot parts of this reality that don't. Go smoothly into one answer. 

Preston: So, so you could say like, we've done the best we can and it's not enough to be disorder.

And then I think a skeptic would say like, you're [00:36:00] essentially like giving autonomy to a delusion. 

Dr. Helen Liljenwall: Yeah. And to even add to that, something that Maggie says a lot too, is like you can't have this dichotomy, um, in like, we don't exist in a vacuum. This is kind of what you were saying, but I'm just repeating it in that like, we don't have access to good treatments.

Often, and like oftentimes patients don't get like adequate trials and the resources that they need and the outpatient resources that they need. We don't have the continuum of care to treat eating disorders properly. Um, so it's difficult to even talk about, you know, considering that they've exhausted all those resources when the resources weren't provided to these patients in the first place.

Right. 

Margaret: And do we just let people, like are we kind of just like under investing in an illness? And undervaluing the population of this particular part of the mentally ill. 

Preston: And then just letting them die and 

Margaret: letting them die. Mm-hmm. Yeah. And saying, you [00:37:00] know, and again, there are extreme, there are cases on either end of the spectrum with this, but I think maybe I'm cynical, 

Dr. Helen Liljenwall: but yeah, I think that's why there's a lot of conversation about it.

'cause there's a lot of, 

Preston: all right, next question. Do speed run that? 

Dr. Helen Liljenwall: Yeah. 

Preston: There's no way to speed. Do you have one market or I have another one. 

Margaret: Um, I. Have one thoughts on someone with a history of an ED treating patients, working closely with patients with EDS. So this is very common, I think in eating disorders.

I feel like more of my like colleagues in nutrition and rds talk about this actually, of that there can be at least an anecdotal sense that it is common for people who go into like. Being a registered dietician to have struggled with their own kind of food rules, food stories in some way? Not always. Um, there's this book called Also Human that is by a clinical psychologist in the UK who primarily works with doctors and one of the chapters is on how people choose their specialties.

And I think this applies with eating disorders, that there can be a lot of beauty and [00:38:00] strength from understanding the pain of something. It can also be extremely triggering constantly to be in the place that caused, caused you pain. And so I think it, it's an, again, this kind of thing where both good and bad can come from having your own experience.

And I think it depends a lot on how much the wound is healed and how much scarred over it is, or how active it is, as well as giving yourself the ability to try the work and. Have a sense of non-judgmental curiosity for whether this is within your capacity or whether you only wanna have a couple eating disorder patients once you actually see what it feels like for you to work in the field.

Yeah, those are my thoughts, Helen. 

Dr. Helen Liljenwall: I mean, I think you're, you're kind of getting at like physician healed myself, right? Where you're like, um. So I think for myself, like when I first started working with eating disorder patients, I really struggled working with the patients because just growing up in the diet and eating disorder culture [00:39:00] that we have, like I would think about like dieting or like noom or like things like that.

And patients would say things similar to what you're getting at Preston, where they're like, I drink caffeine to suppress my appetite. And I would be like, oh, they do that and I. Like, feel like I had like disordered eating thoughts because they're just so prevalent in the United States and like in the Western culture, right?

Mm-hmm. Like we talk about like things that are just kind of normalized that maybe shouldn't be normalized. 

Preston: Mm-hmm. And you're talking to patients that like externalize all this shame. 

Dr. Helen Liljenwall: Mm-hmm. 

Preston: You know, on other people it's hard not to internalize some of it. 

Dr. Helen Liljenwall: Yeah, and I think now, like it's, it's a lot easier for me and in fact it doesn't bother me.

Um, partly I will say shout out to Maggie for patiently waiting to, for me to get rid of my scale for years as she had nagged me because it wasn't helping me with anything. Um, but like with it, like, you know, it's, it's interesting to kind of like relate to patients, but then [00:40:00] also like. You know, like see threads of where they got things, right?

Mm-hmm. Like I could see where they, you know, picked up this particular thought about this particular food and you know, like a lot of like the orthorexia stuff and like really healthy eating too. Um, it's, it's kind of hard to parse out with patients and, and it's interesting treating them when it's like a culture we digest all day.

Margaret: I think also there's this, that the whole philosophy behind modern medicine, especially in the last 30 years is, um. You know, the mind body split, that the body is something that breaks down and dies and is to be controlled. And we all have this fantasy that we can do that as clinicians and make something change, which psychiatry pushes us to question often anyway.

Um, but then that like. I think a lot of us get into med school by being people who pride ourselves on like being good at the marshmallow test and being like, [00:41:00] I don't give into my desires. I like can wait for gratification. I can go into a ton of debt. I'm just gonna be this like good, wise, pure person.

Even if we wouldn't say that. We value that and being in control, being able to get through like 24 hour shifts and then you go into eating disorders and that same philosophy will get reflected back to you through the eating disorder voice of like, well, I'm good when I follow the rules. Like I'm good when I look the right way, when I do everything perfectly.

And so I think to help a patient question that we have to actually have an internal dialogue of that, which is difficult. 

Preston: Yeah.

It takes a lot of skill and a lot of discipline to have that like level of disordered eating. 

And I like some patient patients will say like, this is the only thing I'm good at and I'm really good at this. 

Yeah. 

Like this give, this is what gives me power in a lot of ways. And [00:42:00] then, yeah, and you have a reflective, you and you're like, well my, like, you know, my obsession with academia gives me power or, or working out or other things.

And. It might not be damaging my body, but damages me in other ways. You, you have to stare into the mirror a little bit, 

Dr. Helen Liljenwall: and I think where recovery comes in, a lot of times when talking to patients like that too, is like, what are ways that we can build self-esteem that isn't external validation, right?

[music]: Mm-hmm. 

Dr. Helen Liljenwall: That isn't like those things, those accolades, the things that, you know, like with the eating disorder, sometimes it's a little easier to be like, well, you're not gonna get an award for this, right? Mm-hmm. But like. How do you build your own self-esteem? External of that, especially in medicine when like we get really good at taking tests and meeting the next level.

Like that's how we get to where we are is we're just like really good at taking tests and then we're like really good at, you know, meeting well in clinicals and then, you know, that external validation is like, um, you know, really rewarding. And then you realize [00:43:00] that in fact your self-esteem has to come from somewhere else.

[music]: Well, 

Dr. Helen Liljenwall: controversial 

Margaret: take number two today. Yeah. I have one other question which I think relates to this one, which is someone asked what can friends and family do to notice an ED that in their loved ones and how can they help support 'em? Um, yeah, I think beyond getting them to clinical care, let's say that they're subclinical and that it's more about like someone else asked, like, what do you think the impact of like skinny talk, which is.

I've written enough about this already, so I'm not gonna say anymore about it. But, um, kind of the cultural influences, like you're saying of diet culture. So I think maybe a, a better way to say this question overall, besides getting clinical care when indicated, is how do you help support people to not move towards diet culture towards disordered eating, towards, you know, this body shame stuff.

Like as a friend or family like, or someone with like a daughter or with a friend who [00:44:00] struggled, seems to be struggling with it. 

Dr. Helen Liljenwall: Yeah. I think with that, there's a couple of things. One, like being a good friend right, is really, and a good supportive family member blanket statement for any sort of like struggles that someone's having, but also like, you know, not commenting on someone's body, not commenting on your own body and looking at your self and like kind of your own relationship.

And what we talk about too is like, you know, I'm not expecting bo body positivity, but like body neutrality would like kind of, at a minimum is something to strive for and that you kind of recognize like your body's moving, it's doing things like how great is that? Um, and kind of with that own reflection kind of like.

Keeping that in mind when talking about yourself and kind of talking around other people. Um, you know, we talked about how special meal times are, meal times are so important, especially in recovery. And with that like offering like adequate [00:45:00] distraction, like not talking about what we're eating, but just like being supportive and sharing like that love and that relationship over meals is really important.

Preston: Yeah. What comes to mind when you say that? Uh, like with body neutrality is like, that includes positive comments. Mm-hmm. Saying like, you look so skinny lately. You, you lost a lot of weight. It looks good on you. Or all things that can reinforce those behaviors. And then, um, speaking of kinda reinforcing or punishing, um, like conditioning, not using food as a reward or food as a punishment mm-hmm.

Can, um, help keep like someone's kind with.

Margaret: Idea in this, in the eating disorder field, and related to this question is the concept of like body as self versus body as object. Um, so we hear like objectification, da da, but related to this, like how do you view a daughter if you have a friend? How do you [00:46:00] model talking about being a person who is a body, um, rather than bringing to their attention that their body is something other people are observing or judging or valuing them based on.

And so Hillary McBride, who is coming on the podcast by the way, but she writes in her book, um, the Wisdom of Your Body about this idea and uses the metaphor of a house, which I think is beautiful. And she says, we're born in a house. This house is our body and it has all these great resources that has a roof to keep us warm.

It has a kitchen with like good food in it. It has all these things. And when we're born, we automatically live in the house. But as we get older, we are taught to go sit on the front lawn and look at the house and notice how our shingles are kind of peeling compared to the neighbors. Or this door is kind of wonky off its chin and this.

We need to change this to compare to our other houses and related to social media. I think social media intensifies that desire to look at yourself from outside of yourself rather than live in the sensation of your body. And so [00:47:00] that's an abstract kind of, uh, theory, but it matters in how we frame talking about this.

So you can even say something like. To someone I'm thinking about Helen, which on your wedding, like it doesn't mean you can never compliment someone's like looks, but it means being like, oh my God, you're glowing. Versus like, oh my god, this change. Or some like comments people make about bodies or like comparing you to yourself or others, um, to make it so that it's funny.

Comments that make people realize that they're being judged are going to be ones that can worsen that sense if they already have it in themselves. 

[music]: Mm-hmm. 

Margaret: That was beautifully said. Well, Hillary McBride, doctor Hillary McBride said it. 

Preston: Um, well, I think that's a good place to stop for today. I 

Margaret: agree. Okay.

Helen, I know you don't have any socials you're gonna shout out. Is there anything you'd like to shout out? It really can be anything at all. 

Dr. Helen Liljenwall: Um, Nita, um, the Academy of Eating Disorders and the a PA Eating Disorder Guidelines. Great [00:48:00] Resources and feast. Yes. Yes. Yeah. 

Margaret: Where is Feast 

Is Feast. 

I 

think it's Australia.

Oh yeah, you're right. You're right. Nice. All of those are good places to get more information for patients, for yourself, for clinicians, all of them have different, um, facing resources. 

Parents. Parents. 

Parents. Yes. Friends. Um, Helen, it has been a delight to have you on the show, Dr. L. 

Dr. Helen Liljenwall: Thank you guys. It's been lovely.

I love listening to your podcast, so it's really exciting for me to be here. 

Margaret: Helen will text me and be like, I couldn't, we couldn't talk this week, but I listened to your podcast, so I feel like we did. 

Dr. Helen Liljenwall: I listened. I listened to Maggie on the way home, so I feel like that I'm talking to her 

Margaret: talk. It's different than a pair of social 

Dr. Helen Liljenwall: relationship because I actually talk to her.

Preston: So this is a, this is a Margaret Run episode, so, oh, am I gonna do the outro? Think that means that Margaret is gonna do the outro. Yeah. Okay. 

Margaret: Fair enough. Thank you so much for [00:49:00] listening. Um, how do you think the show is? You guys know, I'm gonna say the thing, which is that reviews do help us. So leave us the review if you like it.

I guess. If you don't like it, that'd be good for us to learn to deal with. Um, you can also come and follow us and talk with us on our Instagram, uh, which is How To Be Patient Pod. You can also come and chat with us and the rest of our Human Content Podcast Family on Human Contact Content pods on Instagram and TikTok.

Uh, you can also contact us in our team directly at How to be patient.com. And you can see more from both Preston and I am unfortunately not Helen, uh, on our own Instagrams and Helen's off the grid, all those things. Helen. Yeah, she's a Yeah. No socials for me. S sneaky guy. Um, we wanna say thank you to everyone who like leaves us questions to be able to.

Format these episodes so that they fit the needs of everyone listening, um, in this episode, even though it's gonna come out later. Thanks for everyone who came to our talk at a PA and spoke with us. Uh, you can watch [00:50:00] full video episodes of the podcast on Preston's YouTube channel over at its pres row. Um, we are your host, Preston Roche and Margaret Duncan.

Our executive producers are Preston Roche, Margaret Duncan will Flannery Chris. Flanary Aaron, corny, Rob Goldman and Shahnti Brooke. Our editor and engineer is Jason Portizo, and our music is Via Omer Ben-Zvi. To learn about our program, disclaimer and ethics policy, submission verification, and licensing terms in our HIPAA release terms, go to our website at How to Be patient pod.com or reach out to us at how to Be patient@humancontent.com with questions or concerns.

How to be patient is a human content. Production.

Preston: Thank you for watching. If you wanna see [00:51:00] 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 I'm gonna go dance in the background.