Eating Disorders Across the Spectrum: Recognition, Assessment, and Evidence-Based Care with Erin Alfree Williams - Part 1

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Transcript

Speaker 0:30

Hello and welcome to Mind and Medicine, a Sentara podcast. I'm Tommy Bateman, your host, and today we will be meeting with Erin Alfree Williams to talk about eating disorders, a very complex topic. But before we begin, some important CME announcements. This episode is accredited for AMA PRA Category 1 credits. For full accreditation, designation, and disclosure information, please refer to the show notes and now the show. I'm so glad you can join us today talking about this very difficult topic with eating disorders and and treatment. But we're going to spend this first part really talking about what an eating disorder is. But before we do that, tell us about yourself.

Speaker 1 0:45

Yeah, it's great. Well, thanks for having me today. Uh again, my name is Erin Alfrey Williams. I'm a licensed professional counselor for the state of Virginia. Um, and I've been in the field now for uh about almost 20 years working in acute care settings, inpatient settings, uh, crisis assessment. Um, but in that experience, uh spent three years, uh almost three years, working at the Center for Eating Disorders in uh Towson, Maryland. And then uh during my time at James Madison University's Counseling Center, worked on the Hope team, which was the interdisciplinary team that supported students with identified eating disorder or body image issues. Um, so this is a topic that is um uh pretty near and dear to me. Uh, just growing up in a culture, I was a dancer throughout my life and in sort of the world of ballet and and performance art, you know, um saw some of this happen and occur. Um and then, of course, with my background in mental health, also have noticed um how complex and how prominent um this issue shows up in individuals. So um happy to be here today and have a discussion about it.

Speaker 2:03

Thank you for that. And really, truly, you know, the word complex is what you used at the very end there, because you know, in my experience, uh an eating disorder isn't just having food issues or or you know, wanting to control their weight or anything like that. It goes so much deeper than that. In fact, it may not, the core is you may not have anything to do with food at all, but I want to I want to ask you because it always just flummets me. So let's start. What is an eating disorder? Let's just start at the basic.

Speaker 1 2:31

Yeah, yeah, great question and a good place to start. So an eating disorder um in its most simplistic form is essentially a disturbance. And and I would even maybe attach the word severe disturbance to to eating and and and how um people care for themselves nutritionally. Um it's a disturbance of eating behaviors um and is related to the emotions and thoughts around eating and about food and about your body. So in a in a very simplistic way, I think that that captures what an eating disorder is.

Speaker 3:10

Gotcha. Gotcha. So yeah, it let's go a little bit deeper than that. You you said that um it is about food or around food, but um tell me a little bit more about that. What's the what are the emotions behind that that people often feel?

Speaker 1 3:25

Yeah. Well, like you said, it um as you referenced right before that, you know, it's sometimes it is about the food, sometimes it's not always about food. Um, I think uh a couple points to capture here um would be that um eat eating disorder, when we talk about eating disorders, um I like to think about it in the way of how pervasive a topic it is. Everybody has uh a body, everybody has to eat to survive. This is one of those things where it affects everybody in some way, shape, or form. Just our perceptions of eating, our relationships with food, um the culture and the family dynamics that we grow up around, um, the way the way food and eating and meal times are viewed amongst our families, our communities, our cultures. And so it is something that's very prominent in individuals' day-to-day life. Where it becomes a disturbance, I think, then kind of goes into those experiences and the emotions and the thoughts that you have around food. You know, are your experiences with food joyful? Are they celebratory? Is this a time for community and sharing and engaging with others? Or does it become a time of stress? You know, is this a time where you know something occurred that was bothersome or traumatic or was a source of criticism? Um, and so I think it it really depends on the dynamics and and the ways that we developed a relationship with food throughout our lives and through various experiences.

Speaker 5:15

So, you know, some people may assume that behind an eating disorder is a personality disorder or some sort of anxiety, uh, but really it could be a whole range of things that manifest into some sort of uh uh disruption in disordered eating.

Speaker 1 5:31

Oh, absolutely. It is it is in my experience, just working on the clinical side, but then also just you know, uh just in life in general. It is rare that an eating disorder is not co-occurring. There is usually something else happening, whether there's a substance use, a trauma history, um, like you said, maybe, maybe a personality, a maladaptive pattern that, you know, people leaned into a disordered eating pattern to, you know, kind of find some sense of control or um, you know, that maybe there were some sort of comfort in in the behaviors they were engaging in. Um so so yeah, I think that's that's probably what adds to the complexity of eating disorders is just the fact that it's never just an eating disorder. There's usually some other things with it.

Speaker 6:27

And then that leaves me to ask too, you know, of course, we we speaking of eating disorders generally, but is it is it of course it's useful to split them up into their categories, bulimia, anorexia, and so on. But when it comes down to drilling down to the psyche behind it or the co-occurring, does the differentiation between the different types of eating disorders necessarily, and of course it matters, but does it matter when it comes to your approach um to how you're treating it?

Speaker 1 6:57

Yeah, great question. I um that is something that's always a hot topic, I think, in in the the mental health community is sort of the value of diagnosing and and and is there what does that mean for someone? Um and I say that because yes, there is value. I don't want to take away from the fact that there is value in clarifying diagnosis, because by clarifying diagnosis, it it gives some structure, um, particularly to the approach of treatment and you know what might be recommended for an individual. The diagnosis is also going to help inform maybe sort of the medical side of treatment that needs to happen, because it's gonna take into consideration some of those health concerns. Um however, on the mental health side, I think it is important to acknowledge we want to be careful with diagnoses because diagnoses in and of themselves can be exclusive to somebody presenting with a eating disturbance. Um, you know, diagnostic criteria for various eating disorders can be very specific and doesn't quite capture the continuum and and sort of the scale that um that eating disorders can can um occur. I think it also by by just focusing on the diagnoses themselves, we kind of take away from the fact that something could be brewing and there's opportunity for early intervention. Um but again, some of you know, I think it's twofold. It's like it's helpful to have a diagnosis, but we also don't want to get locked or fixated into one.

Speaker 8:43

And and and thank you for answering that way. I didn't want to get too far in the weeds of treatment yet, um, but kind of indicating the nature of what an eating disorder is. It's as you said, if we pigeonhole or excuse me, get too specific in the diagnosis, we may be ignoring the broader spectrum of what's going on. So it's hard to say, or maybe it's dangerous to get to too specific sometimes.

Speaker 1 9:07

Correct, correct. I think and and this really goes into maybe something we'll touch on at a later time, but but sort of the value in screening and having a thorough assessment to really determine what is someone's relationship with food, what is someone's perception or the relationship with their body. Um, in those realms of food and body image, you know, where are points that people feel stressed? Where do people feel like they um are maybe lacking in some ways in terms of their esteem, their confidence, their their sense of self-worth, and all of those things, you know, paired with just life experience can can really give a comprehensive picture to what somebody might be struggling with.

Speaker 9:58

So and you and that leads me to think too, wait, wait a minute, I I stress eat. Um or sometimes I'll go a day without eating just because I'm busy or I just don't think about it, or whatever, you know. I think all of us have had um days where food has been our comfort, um, or or something like that. So, what is the line between normal quote unquote um interaction and relationship with food and uh disorders, something that you you would have to end up, you know, uh something you would write down as a diagnosis at that point. What what's is there a bright line or is it a spectrum?

Speaker 1 10:36

Yeah, it again, I I think it falls along those lines of a spectrum. You know, everybody um is gonna have different life experiences, they're gonna have different parameters, they're gonna have different thresholds. Um I think the same goes along you have to consider sort of the physical composition of every individual. You know, everybody's uh physical health is different, their metabolism rates are different, you know, their their body shapes, sizes, and needs are different. And so again, I think that's where the value of thorough assessment comes in because there has to be sort of an individualized lens to figure out okay, here's sort of a standard parameter for what's healthy and what's not healthy, but but how does it apply to that person, you know, and and factoring in pieces like religious preferences, you know, sometimes some religious faiths um really, you know, go through various times of the year that they're fasting, you know, does that necessarily mean there's an eating disorder? Not no, not really. Um, so I think it's really coming down to a conversation with an individual to find out, okay, is this normal for you? Is just is this sort of a random occurrence because of maybe another stress or concern or fear going on in your life? Was there a period of acute illness that maybe changed how you were eating or how you felt about yourself? But then more importantly, you know, what was the rebound from that? You know, were you eventually able to return to normal patterns for things? Um, you know, or was this something that became ongoing, um, such as you know, what we saw with the COVID pandemic, when a lot of people got very focused on healthy eating. Um, there was a surge in eating disorders after that because a lot of people, why they got very focused on that, it then started to transpire into a day-to-day practice where it was becoming obsessive and compulsive in nature. Um, and so I, you know, I think you put it in a good way. There, there's a spectrum there, and it always requires a very thorough assessment and sort of view of figuring out, you know, what's a healthy parameter, what's a threshold, what's a need for somebody, but then specific to that individual, what's ongoing, what's changed, um, and and what becomes disruptive to their own health.

Speaker 13:03

So and that's really interesting about the uh you know, the the spike in disorders during COVID. Um so that leads me to think though, that you know, you mentioned the COVID pandemic, and I bet a lot of those people were trying to be healthy, but they didn't see themselves as having a disordered eating pattern. So I don't think they would come into your office saying, Hey, I have an eating disorder. You know, how would a doctor, nurse, nurse practice, anybody that, you know, someone comes in with some sort of illness screen for that when the person that's sitting in front of them doesn't think they have a disordered relationship with food?

Speaker 1 13:38

Correct. Yeah. No, another great question. Um, this is something during my time at JMU, we we talk about a lot of how do you assess and what are those questions that are important to answer or to ask when you're screening someone through this? Um and it goes down to the basics, you know, um, just asking people, say, tell me tell me about your eating patterns. You know, are you someone, do you eat two to three meals a day a day? Are you someone that sits down to meals? Um, you know, what is the variety, what are the variety of foods that you're eating? Sometimes that can give you some insight if if people are very limited or um, you know, screening through do you have any food aversions? Um, and that's really kind of looking along those lines of RFID, you know, and seeing do people have avoidant and restrictive patterns that um maybe they were unaware of that there's a terminology for it? Again, it doesn't necessarily mean that it's problematic, but it gives you a window into you know how someone approaches food and what they think about food. I think the other side of it is then asking questions about the relationship with their body. Um, you know, do you exercise? And if you do, how often do you exercise? How do you feel when you don't exercise? Um and and that a lot of times will give you uh some insight and and some recognition of like, okay, this is someone that really is maybe sitting with thoughts about their body and what they're eating. Another popular question that I would often ask people when I was assessing them is how much of your mind space is taken up about thoughts regarding food in your body, uh, food in your body image? And a lot, and many, many times that was sort of my in question because it really brought people's awareness to, oh my gosh, I am thinking about this a lot. And, you know, I didn't realize that the first thing I'm doing when I wake up in the morning is looking in the mirror and you know, kind of giving myself the different angles to see what kind of shape my body's in. And that kind of helps generate and lead you down some more questions about, okay, where is this coming from? Why do you think you do that? Um I think also questioning some of the standard things, you know, um, have you noticed any changes with weight loss or weight gain? Um, you know, and if you find anything happening there, going through the normal queries of, you know, is this illness related? Was this maybe a stress related concern? Um, you know, anytime someone's going through major transitions or lost, that can create a stress response. And people, like you said, either stress eat or stress, not eat, it's the way you put it. Um I think I've just lost my thought.

Speaker 16:38

That's okay.

Speaker 1 16:40

So I think I just lost my thought.

Speaker 16:42

That's okay. I lose my thoughts all the time. I haven't found them. Um follow-up on that though is when do you say, okay, that way of eating's a little different? In fact, that way of eating is not even really scientifically supported, but it's not an eating disorder.

Speaker 1 17:04

Yeah. Um those ones I think are very hard because they fall into that odd category, I think, of like what they name now as RFID, the avoidant restrictive um eating disorder. And maybe even OSFED, which is the otherwise specified, I think it's the trendy term for a not otherwise specified eating disorder. And again, this is where I think the questioning in terms of how disruptive is this to your mind space throughout the day? What are your thoughts and feelings about it? What are the goals with your eating pattern? You know, and a lot of times that will open up some understanding of, okay, maybe this isn't something that's terribly problematic. But again, are we starting to flag something that could potentially become problematic? Um and again, it usually for some people, eating disorders can can start off very innocently, you know, with this effort of, you know, I thought it was a good idea that maybe I work on, you know, some weight loss goals, or I, you know, I want to get into clean eating, which is what we see with the orthorexia. Um and again, it's just then for whatever reason, patterns of behavior, people become overly focused on it because they initially get some good feedback from the things that they implement or the things that they're doing, and they start to take it to, you know, sort of what those I would say is sort of the extreme measure. We start to lose some of that balance um sort of in that that healthy versus unhealthy realm.

Speaker 18:45

Sure. So and that that that's interesting because you know when I think eating disorder, and I think, yeah, uh most of the public when they think eating disorder, and by the way, just because I'm an LPC doesn't mean I work with eating disorders a lot. I I did not. I did not. That was not my not my jam, didn't know how to do it. So thank you, Aaron, for doing what you're doing.

Speaker 1 19:06

Sure.

Speaker 19:06

Um, but when I think of it in the stereotypical way, I think anorexia, bulimia, it's really bad, or overeating, you know, and it's it's uh darn near death sentence, you know, it's really severe, uh, and it's really it's really uh entrenched in that person and the the prognosis is poor. Can you tell me a little bit about that? Is that a stigma or is that something that has a basis in reality?

Speaker 1 19:35

I think a little bit of both. You know, there certainly are people out there who are who kind of fall into a very severe category. Um and and it is it's incredibly, incredibly difficult to work with someone in that realm to recognize um you know the behaviors you're engaging in, the the perceptions that you have about your state of health are are extremely disordered or are extremely distorted, I guess is the way to put it. And you're almost kind of combating a level of delusion, you know, with somebody when they're at that level. Um is there stigma? Absolutely, absolutely, because anybody in mental health, there's a stigma, you know. I think there's hopefulness that that mental health stigma is is not as strong as it was in the past, it's not as much of a taboo subject. Um while I think we've made progress in that area, I also think that we sometimes venture as a as a culture into over pathologizing certain things. And so, you know, being careful not to make it sort of a badge of honor of like, I've got an eating disorder. Yeah, yeah. So so again, it's like always it's always sort of a catch 22 of trying to find like where where is that that that window of this is how we create awareness, this is how we create understanding, we want to have good education. And again, I can't stress the the idea that it's individualized because every person is different. There, there may be a general structure or approach to treatment, but really what's going to apply to someone's success in their physical health, their mental health, their emotional health, you know, what's available to them, it it has to, it has to come in a very um individualized approach.

Speaker 21:34

And I think that's where we will stop this segment because uh I do want to talk a whole lot more about treatment, um, you know, what the prognosis is, but as you said, it's it's so individual. So uh come back and do we end part two, Aaron.

Speaker 1 21:47

Yeah, it sounds good.

Speaker 21:51

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