Podcast: Recognizing and Addressing Eating Disorders and Body Image Issues

Episode Transcript

Jenn: Welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Jeff: Hi there, and welcome. My name is Jeff Bell, and on behalf of McLean Hospital, I’d like to thank you for joining us for this episode of our educational webinar series.

Our focus today, eating disorders and body image issues. These can be rather complicated topics, they’re also extremely important ones as they involve our most basic relationships with food and our own bodies.

So, we want to take some time today to talk about conditions such as anorexia, bulimia, and body dysmorphic disorder. They’re all treatable, that’s the good news, but treatment requires recognition of the conditions, and sometimes that itself can be quite difficult.

Fortunately, we have an expert with us today who can provide some guidance, guidance for identifying when someone is struggling with an eating disorder or body image challenge, and can also walk us through the options for effective treatment.

Dr. Roberto Olivardia has been treating patients for the last 20 years, in fact, since his internship at McLean Hospital. He runs a private practice in Lexington, Massachusetts, where he specializes in the treatment of body dysmorphic disorder, OCD, ADHD, skin picking disorder, and males with eating disorders.

We have turned to him numerous times before for this webinar series, and Roberto, we are thrilled to have you back with us today.

Roberto: It’s great to be here, Jeff, always a pleasure.

Jeff: Well, thank you, we are going to be covering a lot of ground today and referencing a number of clinical terms over the next hour or so. I thought we’d start by asking you to give us some working definitions, in fact, three of them, body image, eating disorders, and body dysmorphic disorder, can you help us understand those terms?

Roberto: Sure, so with body image, it’s very important to distinguish, body image is different from appearance. So, appearance are the sort of objective measures, what color our hair is, how tall we are, or how much we weigh, these are kind of very concrete, objective items.

Body image could be aligned with our appearance, or it could be totally different from our actual appearance.

So, body image is the way that somebody sees themself, but also how they feel about what they see, how they evaluate, kind of how they feel about their bodies, their relationship to their body, how they might perceive other people are perceiving them.

And our body image can be, it really can intersect with lots of different things, the culture we live in, our gender, our socioeconomic status, the time of year, our body image can really fluctuate, so it’s not always necessarily a consistent thing within individuals.

Now, for a lot of people, even within a typical individual, you’ll still see fluctuations in body image based upon, again, time of year, if somebody had a big meal, they might have a very different body image than when they didn’t have a big meal.

And then with some of the people we’re going to be talking about today who are affected by eating disorders and BDD, they can wildly vacillate, and really, body image could be very, very far away actually from how a person actually looks.

So that’s the term of body image, now, when people have a negative body image or a distorted body image, which means how they’re seeing themselves is very different than how other people would see them, it certainly puts them at risk for eating disorders.

And with eating disorders, there are different DSM-5 diagnoses, we have anorexia nervosa, which is mainly characterized by a severe caloric restriction, someone who’s basically starving themselves, and oftentimes with anorexia, it’s due to a fear of fatness, a fear of gaining weight, although we’ll talk later that not all eating disorders have to have negative body image.

Bulimia nervosa, which includes binge eating episodes where you’re eating a lot of food, more than what typically people would eat in a certain period of time, and then feeling a lot of disgust or feelings of worthlessness after binging, and then having a need to compensate for that binge, so that could be in the form of self-induced vomiting, laxative use, fasting, overexercise.

And then there’s binge eating disorder, which is fairly new, and the DSM-4 started to sort of put this term on the books, which is the binge episode without the purging. And something that really is sort of been more and more recognized.

And then you have sort of these categories of what we call avoidant and restrictive food intake disorder, other eating disorders that might not neatly fit into those anorexia, bulimia, binge eating categories.

But, all those underlie basically, are issues that can compromise somebody’s medical health, certainly taks a toll on their psychological health, and obviously are very, very concerning, because eating is a natural way that we survive.

And so when people struggle with eating disorders, it is a daily, hour-by-hour struggle, it can be a very, very difficult condition to have and tormenting for people who struggle with it.

Now, body dysmorphic disorder is a little bit different, it’s actually BDD, is sort of housed under the umbrella of the obsessive compulsive spectrum disorders, and most people with BDD don’t have an eating disorder and we can sort of tease that apart.

But, BDD is characterized by a preoccupation with a part of the body or multiple body parts in which an individual often will have a very distorted image about that part of the body.

It could be their nose, their hair, their height, their muscle size, and they often will think it looks ugly, deformed, inhuman not just that they’re a little dissatisfied with it, they really feel that it just looks just horrific.

And it’s often coupled with a lot of obsessive thoughts about that body part, and then compulsive behaviors in the form of whether it’s excessive grooming, mirror checking, camouflaging behaviors, and, or severe avoidant behaviors, people who won’t leave their house because they feel that they look too ugly.

And BDD’s a very serious condition, about 17% of people with BDD attempt suicide, a number of people with BDD are housebound and have a lot of shame of having the disorder. So those are kind of the main things that we’ll be talking about today.

Jeff: Yeah, that’s really helpful to break all that down. Is it possible for someone to be battling more than one of these conditions at the same time?

Roberto: Absolutely, and in fact, I mean, usually when working with any of these populations, it’s very important to screen for those other diagnoses. So when I’m working with someone with BDD, for example, even if the BDD is around their nose, I always screen for whether there are issues with eating and disordered eating.

And I can give you an example of that is, I once had a patient, he had body dysmorphic disorder around his nose, he thought his nose looked disgusting and repulsive, and again, their body image is quite distorted, anyone who would look at this person would think there’s nothing unusual about this person’s nose.

So, when I screened and asked them about eating behaviors, it turns out that they did have engaged in some very disordered eating, but not for the reason that people would think, so they did restrict their calories, but not because they feared gaining weight, but this person had read that if you lose fat on your face, it can alter sort of how your nose looks.

And so, they would engage in these kinds of behaviors of restricting some calories, but then binging, because they were trying to sort of distribute body fat on their face in a certain way to have their nose look a certain way.

So, it didn’t have to do with their weight, it had to do with their nose, so sometimes even the disordered eating could attach itself with the person with BDD. People with eating disorders, certainly a lot of them, although not all, have negative body image.

And in fact, I mean, for a lot of people with anorexia, one can almost conceptualize that when the fear of weight gain, and people with anorexia will often say, “My stomach is huge,” when they’re emaciated, “My thighs are too big.”

One might even argue that that’s a body dysmorphic disorder manifesting itself into an eating disorder, and a lot of times actually with patients that I work with—I work with boys and men with eating disorders who have anorexia or negative body images driving it.

Even when they recover from the eating disorder, we’ll still find that there are some BDD issues that might sometimes transfer to other parts of their body, but it doesn’t mean they have to have all of those things, but yes, you’ll often see them kind of in this intersection between all of those.

Jeff: By way of perspective, what do we know about how common or uncommon these conditions are?

Roberto: So they’re actually quite common, enough that we, I’m glad that we’re doing this webinar, so in the United States alone, about 30 million Americans struggle with eating disorders, of anorexia, bulimia, binge eating disorder, and very disordered eating that can get in the way of their health.

And what’s shocking, Jeff, is studies show that about 10% of people get treatment for their eating disorder, only 10%.

Jeff: Wow.

Roberto: I mean, that is appalling. And I see as our job in the mental health communities, we need to do a better job of making treatment more accessible, less stigmatizing, and for people to understand that recovery is possible.

So, we have a number of individuals struggling with eating disorders, with body dysmorphic disorder, in the mid-nineties when research was starting to even put BDD as a diagnosis, it was shown about anywhere from 1 to 2% of the population has BDD, more current studies are showing anywhere from 2 to 4% of the population could have body dysmorphic disorder.

And keeping in mind that with both of those categories of disorders, they’re not disorders in which people knowingly are always reporting.

So I often see those statistics as an under-reporting, because there’s a lot of shame that these individuals feel struggling with these, they often don’t sign up for research studies, a lot of them get misdiagnosed, particularly people with body dysmorphic disorder can get misdiagnosed.

And a lot of them have depression or have social anxiety disorder but unfortunately don’t get also diagnosed with the BDD, so they get missed even in prevalence studies.

So, it’s much more common, and unfortunately, we’re seeing the numbers rise and we’re seeing people younger and younger get affected by these disorders.

Jeff: Yeah, those numbers are sobering indeed.

Because a big part of our goal today is recognition of these conditions, I want to drill down a little deeper on all of the eating disorders that we’re going to talk about today, starting with anorexia nervosa, what are some of the warning signs that parents and educators and providers can be looking for?

Roberto: So typically with anorexia, you’ll often hear individuals start to talk about, if we’re looking at sort of where it’s definitely driven by negative body image, talking about their weight, not feeling comfortable in their bodies.

Oftentimes it might start with going on a diet in people who engage in dieting kind of behaviors, where it’s “so I can’t eat this, I can’t eat that” food starts to be talked about in the language of “this is good food, this is bad food, I don’t deserve to eat this.”

People who start to now have this relationship with food as feeling very transactional, so it’s not that food is something to enjoy, food is something I have to do to eat, but one really, almost shouldn’t even get pleasure from it, because it’s all about what impact it actually starts to have on the body.

When you start seeing individuals who are skipping meals, they’re looking at themselves in the mirror more, they’re weighing themselves a lot more, they might be asking their parent, “Do I look fat? Do I look bigger than I did yesterday?”

And all of us can understand as adolescents, I mean, we all have heightened body image issues as adolescents, I certainly would not want to revisit puberty, and there’s a level of that that can be normative.

But when it gets to a level where it’s very all-consuming, where an individual might be trying on various outfits to try clothing that might not make them look a certain way or to make them look a certain way, and then certainly weight loss.

And then for girls, oftentimes, although this isn’t the criteria anymore in the DSM like it used to be, but when girls engage in severe caloric restriction, they lose their ability to menstruate, and so the loss of a period is a very concerning sign.

For boys that I work with, they get drops in testosterone, and so in ways it almost kind of like regresses, physically regresses the body to like a pre-pubertal state.

And so when you start to see all of that, that’s usually, those are all signs of, we want to definitely try to get help sooner rather than later because this could spiral very quickly, and especially if somebody let’s say, loses 10 pounds and they get, “oh wow, you look great.”

Especially for young people when they get rewarded in a sense for it, given other personality characteristics that we know about anorexia, could really start a slippery slope.

Jeff: How about bulimia nervosa, how does it differ from anorexia?

Roberto: So, bulimia in some ways, even though they’re both eating disorders, I think that bulimia is a bit of a different animal.

Psychologically what we know about people with anorexia is you’ll often see a lot of other obsessive compulsive behavior traits, sometimes a comorbid OCD diagnosis, they tend to be more restrictive individuals, people who have a hard time even expressing and articulating emotions, being assertive, being more compulsive.

Bulimia on the other hand in general, is people who tend to have more issues with impulse control, so they tend to be more impulsive, their emotions are often out there, but often in a more dysregulated fashion as opposed to OCD, I’ll often see ADHD as a very common comorbidity with bulimia and binge eating disorder.

So these are individuals where they consume and they’re sort of more consumers, and not just in the form of food, but it’s not uncommon for people with bulimia to also struggle with some other impulse control disorder, substance abuse problem, spending habits, porn addiction, gambling addiction, that you sort of see impulse control being at the core for these individuals.

And then on top of that, when they binge eat feeling, having a high degree of self-criticism, that then leads them to want to compensate in these ways that are very, very unhealthy for them.

So, in a way they’re eating disorders and there’s a lot of overlap in terms of skills and treatment, but personality-wise, they can be very different kinds of individuals.

Jeff: Is it difficult to tease out binge eating disorder from bulimia, for example?

Roberto: Typically, with binge eating you just don’t see those compensating behaviors. So, a lot of times actually when binge eating disorder gets underdiagnosed is that it gets conflated with obesity.

Now, not everyone with binge eating disorder is overweight, I’ve worked with many people with binge eating disorder that could be underweight or that could be of typical healthy weight range.

And you have individuals who struggle with obesity, but because of their binge eating disorder, and most people who are overweight or struggle with obesity do not have binge eating disorder, and so we want to make sure we’re not conflating that.

But a lot of times, and I’ve certainly seen it with a lot of patients who might present, let’s say, in weight loss clinics or even with their physicians who are struggling with their weight, where binge eating disorder never even gets assessed or recognized.

An individual could be saying, “yes, there’s a weight issue here,” but there’s this larger issue of “I am out of control with these binge eating episodes.”

And again, and I think especially with men, I’ve seen this even be more underdiagnosed, because it’s just more socially acceptable for men to eat a lot, so if I hear, how many men I’ve worked with over the years who have told their doctors, “Oh, I ate two burgers, a large pizza, bag of Doritos.”

And sometimes they’re like, “Oh, that’s a typical like Super Bowl meal,” and they’re like, “No, no, I was out of control, like I felt very out of control,” and it’s very hard sometimes for them to even get that recognition from the medical community, I mean, and understanding how difficult of a diagnosis that could be.

Jeff: Before we talk about some of the treatment strategies, I want to ask you about the causes of these eating disorders, what do we know about those? Do genetics, for example, play a role in all of this?

Roberto: Yeah, so I think the eating disorders is really fitting into this biopsychosocial cultural model, and so what we know is absolutely that there are these biological genetic underpinnings.

People who struggle with anorexia, you will often see within their family tree higher prevalence of either anorexia, obsessive compulsive disorder, generalized anxiety disorder, kind of again, these sort of body dysmorphic disorder, you’ll typically see in the gene pool, perfectionism, although that’s not a DSM diagnosis, I think it should be, high degrees of perfectionism.

And you’ll often see that kind of within the family tree, so we know there’s this sort of genetic underpinning, and a lot of my patients who have had anorexia, even when they were young children, parents would often report that they were highly perfectionistic, very compulsive about certain things.

They were very sensory defensive sometimes in the sense that they’d be like picky eaters and would feel like very disgusted if something didn’t look right or look good. Even though they were eating healthily, they could almost see those personality traits.

And then we have the sort of psychological part of these personality traits, perfectionism, and emotional restriction, people with anorexia often have a very difficult notion with being out of control or dealing with uncertainty, which again, you see in people with OCD as well.

And so, anorexia can almost be this attempt to almost gain control over your own body, it’s this kind of strange sort of pursuit of autonomy, but of course, what’s happening is that you’re totally losing control of your body when you’re sick, I mean, when you’re ill.

And then, obviously, we all know living in this world that we live in, that there are sociocultural aspects to it, but I always preface this by saying, we don’t want to underestimate nor overestimate the power of the media and social cultural imagery.

There’s a wonderful book called “Fasting Girls” that was written many years ago that really traces anorexia from the 1600s on, and talks about how back in the 1600s, obviously, we had no social media or television and things like that, but the symbolism of anorexia was connected to religious purity.

So the more these girls starve themselves, the more they were basically told like, you are going to be more pure, you’re going to be more connected to God, it had high religious sort of connotations.

It’s not different now in the sense that the messaging, even with, let’s say, girls who are promoted these very thin ideals, boys that I work with who are promoted to be buff, and to be muscular, to be lean, is still this underlying sense of you will be valued more, you will be connected more, whether it’s to peers, you will be loved more, it’s that same kind of imagery.

Now, we do know that the media and all that imagery absolutely contributes to what we’re seeing now in younger people.

I can tell you, Jeff, doing this work for a chunk of time before social media became a thing to now I have absolutely seen an inflection point with the advent of social media, which I think is really not good for young people.

I have very strong feelings about it, and studies show this, the empirical research is showing a correlation of, for adolescents of Instagram, TikTok, and negative body image, so we do live in a culture that is promoting, and lots of companies make a lot of money off of promoting a certain way to look for people.

So when you put all of that together, now for anorexia, for bulimia, you have the same sociocultural parts, and again, the genetic underpinnings typically you’ll see with impulse control.

So people who I work with who have bulimia, either within themselves or within their families, you’ll see higher prevalence of ADHD, substance abuse issues, sometimes conduct disorder, criminal behavior, other like kind of addictive type of behaviors, and the similar with binge eating disorder.

Jeff: We had a question come in that I think speaks very well to the whole notion of threshold on a spectrum here. When does one’s relationship with food become problematic? When does struggling with weight loss become an eating disorder? And what signals are there that there needs to be professional help involved?

Roberto: It’s a great question, because I think within this we’re talking, we have to eat, it’s easy to say, what is a threshold for heroin use? You just shouldn’t be doing heroin period, but with food we have to eat, and we want to eat healthy, I mean, we are told like, eat healthy, it’s great to exercise, so what is that line?

So I sort of break it down in a lot of this way, so when we’re talking about body image, nothing wrong with having your body image be part of your self-esteem, I mean, it feels good when we feel we look good for a lot of people, we get our hair done, we wear certain clothing, people might put on makeup, like all of these kinds of things, that’s sort of part of normative living.

Where I would say are more problematic is if most or a lot of your self-esteem is based upon your body image and your appearance, that’s always a cause for concern, because I can guarantee you, you will look different 5, 10, 15 years than you look right now.

Your sense of humor may not be different for the next 80 years of your life, and your intelligence, and your way that you relate to people, those are crystallized features of our identity, our appearance will change.

And so, if all of your self-esteem is wrapped up into being this weight, or having this much hair, or being this height, that’s going to be problematic, because those things are going to sort of change over time.

Secondly, is if you’re engaging in any behaviors that start to be unhealthy, and if you even question whether it’s unhealthy or not, talk to your doctor, don’t go on TikTok, don’t go Google, because you’ll see it all.

Just talk to your physician in terms of, so I do work with individuals who are engaging in healthy weight loss, and so they were told by their doctors that they should lose weight to help with certain medical conditions, and so we’re watching what they eat, but it’s still engendering a good relationship with food.

So I always find that line too, is when your relationship with food is more that you see food as an enemy, where you feel like, “oh, I can’t have this and if I have it then now I feel worthless,” as opposed to, “okay, maybe my doctor told me not to eat so many cannoli, I had too many cannoli today, okay, how do I make work with that for the next time?”

That’s sort of fine, but if it’s a, “I’m a worthless person,” once you get into that script in your head, it’s very concerning, and even in the absence of unhealthy behaviors.

So, I’ve worked with people who, I don’t know, they have two cookies instead of one at Christmas time and they’re like, “Oh, I have no self-control, I’m so like, what makes me think I can be successful in life?” And they’re just so harsh with themselves, that’s a reason to already start talking to someone, because that could again, it could expand very, very quickly.

If you’re skipping meals, if you’re hungry, and you’re trying to almost go against your natural, what your body naturally needs, certainly if you’re experiencing any health things.

So if you’re a woman and you lost your period or getting irregular periods when you hadn’t used to, if you’re more tired than usual, if you notice your hair, your skin, your nails are a little bit brittle or looking differently.

If you’re noticing like, you’re out of breath more because of this diet you’re on, I don’t promote dieting, it’s more around making just lifestyle changes for people who, let’s say, if they want to eat healthily, that’s fine.

But it’s not about, I can’t eat this, as much as how do I eat things and regulate what I’m eating and use it in moderation, and enjoy it, I mean, we’re meant to enjoy food in that kind of way, but also paying attention to your self-talk.

When you look in the mirror, what do you say? Do you say, “Okay, I’m ready for the day, and I like the way my eyes look today, and I like this color shirt that I’m wearing,” or every day are you saying, “Oh, you’re so ugly, oh, you’re so fat, oh, your life would be so much better if this,” that’s concerning.

Because with body image, with all of these disorders we’re talking about Jeff, it’s beyond the condition itself and it’s more how it infiltrates a person’s sense of themself, beyond even mealtime and beyond in front of the mirror.

If you feel like an ugly, worthless person, then that affects and infiltrates every situation that you’re in, and certainly I see that, that’s the other thing, if you’re avoiding situations because, oh, I don’t look good enough for that or, and limiting yourself, ‘cause these disorders can make your world very, very small, and that’s what we don’t want to happen.

Jeff: So before we segue into body dysmorphic disorder and talk more about BDD in particular, let’s talk about treatment for eating disorders, based on what you’ve shared so far, Roberto, it sounds like that could be complex, that process, and might involve a number of different team members.

Can you walk us through how that team might come together and how they might put together a treatment plan for a particular individual?

Roberto: Yes, so eating disorders do often require a team approach, and because you’re talking about a psychiatric disorder and a medical disorder, I mean, something that is now interacting with your health, with your medical health.

So typically, you’d have a therapist, a psychologist, and working with all the underlying mechanisms of what contributed to the eating disorder, what skills through cognitive behavioral therapy or dialectical behavior therapy, as well as self-esteem.

And it could be sometimes interpersonal or psychodynamic therapies of helping a person understand who they are aside from their body and their appearance and those kinds of ways.

But also you want to make sure that this is an individual who’s healthy, and so you’ll have a physician typically on the team, ‘cause I’m not a physician, I don’t measure vitals, I don’t know what the correct blood pressure always is for a certain individual.

Especially in working with adolescents, we want to make sure that these people are growing, because one of the biggest concerns with eating disorders, especially with young people, is that it can really interact with their development that could sometimes, if it’s severe enough, could be irreparable, and that’s what we don’t want to happen.

So, I have a physician on the team, and they look at the growth curves, they look at the vitals, and blood pressure, and all of that information, and then typically you’ll have a nutritionist or a dietician on the team, because I know generally what are good foods to eat or not, but I’m not a nutritionist, and especially in working with someone who is compromised nutritionally.

Particularly in the case of anorexia nervosa, having a nutritionist who could work with that individual, ‘cause sometimes it’s not so easy, obviously, I mean, that’s why to say, “Oh, you just need more protein, have some peanut butter.”

Well, that’s not always going to fly well with these patients, so you have to work with a nutritionist to find something that’s going to be tolerable for someone to eat, but at the same time we need them to have taken those calories so that they’re thinking more clearly.

I mean, one of the things that is so, I always tell people that is so difficult about anorexia is that anorexia nervosa, particularly even more so than bulimia and binge eating, is overriding, and the most essential survival mechanism is to eat, to survive.

And so when people get to a place where they are not eating and their body is almost adapting to that, I mean, they’re way past the plan.

I mean, recovery is always possible, Jeff, and I always say this.

And I got permission to say this from a client I worked with years ago who was a 72 year old man I worked with who was struggling with anorexia and bouts of bulimia throughout his life since he was 12 years old and recovered at 72 and spent the last 10 or 15 years of his life free of it, and he said it was completely worth it.

Jeff: Wow.

Roberto: So, you are never too old to get help, and at the same time, the longer you have it, the harder it can become to treat it. So, you’ll often have a psychiatrist also in the team to prescribe medication, sometimes the physician on the team can also take on that role of prescribing medication.

And then in the case of young people as well as some adults, you might have sometimes family therapists or a couple’s therapist, because eating disorders and these issues don’t, I mean, they obviously affect the individual, but they affect the people around them who love them and who feel helpless in terms of trying to help them through a lot of these problems.

Jeff: We sometimes hear about hospitalizations needed in association with treatment of anorexia or bulimia. At what level does that become necessary?

Roberto: So typically when someone is at a level that is medically unstable for them, and so you look at again, at vital signs, I mean, patients who might be fainting, they can’t get through a day, they’re just not taking in sort of their calories, their heart rate is very, very low, that outpatients seeing a therapist like me once or twice a week is not cutting it.

It’s just throwing jello at something, they need something that’s much more intensive and under medical care, so in very severe cases, they need to be in a hospital, sometimes getting fed through an IV just to get calories in them, because keeping in mind with anorexia, your brain is not thinking clearly.

So the more deep someone gets into anorexia, the less able they are to think their way out of it, because their brain is literally not working.

It’s almost like the more heroin somebody takes, the more impaired they become to get themselves out of it, thinking that’s why they have to go to detox and rehab.

You need something that’s big enough of an intervention because the problem has become big. Now with bulimia, what a lot of people don’t know is the mortality rate for anorexia and bulimia are fairly equivalent.

And it’s also important to note that a lot of the mortality rate of eating disorders is due to suicide, that this is a population of individuals who can feel very hopeless and very worthless and it can get to feeling very suicidal if they don’t get help.

But with bulimia, people assume, okay, well if the person is taking in calories, well, they’re not starving to death, do they require hospitalization?

The issue obviously, I mean, just even with binge eating disorders, just any exertion that it puts just on your body in terms of whether it’s weight or even just with eating very fast, eating a large volume of food in one sitting can result in a lot of medical issues, but the purging behaviors, particularly with self-induced vomiting and laxative use is extremely dangerous.

I always pose to patients and having them understand like, what our bodies are on like an evolutionary cycle, and when we think about vomiting, our bodies are only meant to vomit when we have a toxin in it.

So our ancestors, if they ate a berry off the bush and they vomited, they learned pretty quickly that’s a poisonous berry, I’m not eating it again, it’s only supposed to come in sort of small amounts or if we have allergies to something.

So when somebody is purging and doing it on a regular basis, the brain and the body are kind of confused by that, and what ends up happening is our bodies always try to adapt to what we throw at it.

It starts to see this conditioned response and it’s very easy to start to almost the brain thinking that food or the particular foods that people binge on, which are typically going to be high sugar, high fat, high carb food, as almost toxic.

So that when people get into that cycle of binging and purging, the more they purge, the more that when they start binging, they almost feel literally like how people would report being when they’re food poisoned, like it just has to come out of them, because now they built this sort of conditioned response.

But the problem with that is that when we’re throwing that, when our body’s experiencing that, it messes up your electrolytes, which are basically, if you think of them as sort of hormones that regulate our heart rate amongst other things, and then that starts to mess with our heart.

And so it’s not unusual, and I’ve worked with people as young as 19, 20 who have had cardiac arrest, luckily have survived, due to binging and purging, and there isn’t the correlation of, oh, you have to binge, you have to purge 10 times a day for this many times to have that happen.

I worked with someone many years ago who was basically in the beginning of bulimia and had a cardiac event, and so it’s really gambling with your health, so when you start to engage in these behaviors and it feels out of control, you might need something more intensive than outpatient care.

Jeff: Yeah, these are serious issues we’re talking about, and we’re going to come back and address some very specific questions that have come in from the audience about eating disorders, but I want to take a couple of minutes to talk about BDD, body dysmorphic disorder.

And let me start with this, it’s not uncommon for any of us to have challenges with a particular body part, I might not like the look of my nose, for example, but how does that differ from an actual BDD episode?

Roberto: Yeah, so BDD in some ways one could look at it as a severe end of a spectrum, I think of it almost as like, not even on the typical spectrum that we would see.

So typically, if we think about body image, I could poll anyone on the streets and say, “Are there parts of your appearance that you love, that you like, that you feel neutral about, that you dislike and that you really don’t like, or even hate?” People will probably be able to endorse all of them.

Typically though, people will have a couple parts that they might really love about their appearance, some things that they really don’t like, and most things are kind of just neutral, now, people might say, “Oh, if I had a million bucks and there was no risk of surgery and all that, if I could snap my fingers and make this happen, would I do it?”

Sure, but it’s not enough that it really gets in the way for people, but even the things that people are dissatisfied with, ‘cause we’re all dissatisfied with some aspect of our appearance.

The dissatisfaction is still within this realm of, okay, yeah, I would like to be 5/11, but I’m 5/8 and, ugh, I’m kind of bummed about it, but there isn’t this sense, with BDD you start hearing words like ugly, repulsive, inhuman, deformed, like words that now are beyond a kind of on this line of satisfaction, dissatisfaction.

It’s almost like on a separate plane in a way, the kind of plane where the thinking becomes, I don’t even, I’m not worthy of being around other people, I’m offending people with my appearance, people are looking at me when I look in a room and they’re taking special notice of me, that BDD thoughts can do that.

Whereas most of us, even if we thought, “okay, if I walk in a room and I’m five feet tall, people might notice,” “okay, if I’m a shorter guy than usual,” but that’s as far as it’s going to go, with BDD, the thought is, “they’re going to notice, they’re going to focus on it and fixate on it the way that I’m fixating on it, they’re going to think that because I’m that height, I shouldn’t be approached, loved, talked to, deserving of a promotion.”

Like, it gets, everything gets sort of subsumed into it where it literally now feels like that person’s survival is rested on this body part. And so, I’ll hear things from patients of mine who will say, “There’s no way I’ll get a promotion for that job because of the way my hands look,” or, “If my teeth were whiter then this would happen.”

And so, there’s all of these what we call cognitive distortions, which are ways that we think that can be inaccurate around this sort of overvalued ideation of body image, and then of course, with BDD, you get into these compulsive behaviors, that even if somebody, let’s say, has a bad hair day, they do the best they can, but they still leave the house and they go to work.

The person with BDD may not go to work that day, or they’ll have to wear a hat, or if it’s a windy day, I might have patients who are like, “Oh, I’m not leaving, ‘cause then my hair will get a mess and I don’t want to be seen that way.”

If they’re concerned, I work with men who have something called muscle dysmorphia, which is a subtype of BDD, despite being in good shape and being physically fit, they won’t take their shirts off at a beach or a pool, because they fear that people will be like, “Oh my gosh, that guy’s so scrawny, what makes him think he can be out here?”

So, it gets on that level and it’s all-consuming, I mean, studies show that most people with BDD are thinking about that body part or parts more than eight hours a day. I mean, it’s not something that’s casual in the way that we would see with typical body image.

Jeff: So generally speaking, what does treatment look like for BDD?

Roberto: So, with BDD, treatment is possible and recovery is possible and I think that’s the biggest takeaway I want people to get from this webinar, ‘cause although these I want to validate, these are very difficult disorders and recovery is possible.

So, with BDD, it’s a combination of the cognitive behavioral therapy, but particularly, the behavioral part is something called exposure and response prevention treatment, which is borrowed from what we know about obsessive compulsive disorder treatment.

So if I’m working with someone who is spending three hours getting ready in the morning putting on makeup, painstakingly, we try to limit that to 15, 20 minutes.

If somebody is avoiding, it could be, let’s say, being under fluorescent lighting, because they think it shows their skin in a worse way, then we will do exposures of going under fluorescent lighting and being able to interact, ‘cause we can’t always control those things.

Certainly, any other behaviors that they might be engaging in, whether it’s skin picking behavior, which is common amongst people with BDD, we try to sort of decrease and then expose themselves to those situations that they might be avoiding.

And then even with medication, I mean, psychopharmacological research shows that people with BDD as compared to even with people with OCD, ‘cause most people with BDD do not have OCD, even though they’re kind of cousins genetically in the same sort of obsessive compulsive spectrum.

But studies will show even pharmacologically, people with BDD typically require higher doses of SSRIs and it can take longer for people to start to see a difference with BDD versus OCD.

So, there’s something, maybe because it’s just them, like the person that they’re sort of walking around with that is almost like a constant exposure, just even being seen in public is an exposure.

But I’ve worked with people who are housebound for a decade because of their BDD, so it’s a combination of that cognitive therapy, mainly that behavioral therapy, medication, and the interpersonal therapy, helping these individuals be able to see the other parts and the most more important parts of their identity and their sense of self, that allow them to really connect with other people.

‘Cause people with BDD also have these distorted notions of, “if I just looked perfect, I would have no stress in my life, if I looked perfect, everyone would like me.”

Well, that’s not true. First of all, there’s no such thing as looking perfect, like I’ve worked with models, I’ve worked with people who are on the covers of magazines, who you and I would think is a good looking person.

And they could still have BDD or an eating disorder because they’re looking at another person, another celebrity model or whoever that they’re comparing themselves to. So, there is no such thing as perfect, but two is that, there is nothing that totally immunizes you from stress.

And this is a very common feature I find with people with BDD is that they have a hard time managing stress and anxiety, so part of the treatment is in skills and managing just anxiety and stress and knowing that putting kind of all their eggs in this one basket, “if I look a certain way, then everything will just be fine.”

That’s not true, in the same way that someone might think “if I was a billionaire, everything would be great in my life,” well, that’s not true, that we know there are lots of aspects to what make people happy and content.

Jeff: So Roberto, we’re down to about 15 minutes and the questions just keep coming in, so I’m going to bounce around to a whole bunch of different topics at this point.

Roberto: Sure.

Jeff: Question is this, what are your suggestions for working with clients who are extremely resistant to change or to engage in any eating disorder treatment?

Roberto: Yeah, and it is a disorder that definitely is prone to that and it’s not that people don’t want to get better, I always want to emphasize that, people who struggle with eating disorders are tortured by this condition.

And at the same time, the nature of the condition is, it almost tricks the brain into thinking that if they didn’t have the eating disorder, it would be worse, so like the idea that, oh, if I gain weight, and if the person, let’s say, who has a fear of gaining weight, that’s going to be far worse than this and that doesn’t happen.

So what I usually encourage for loved ones, parents, and spouses, is to start with what you observe, and the stuff that can’t be debated, I’m noticing you’re only eating one meal a day, and in addition to that I’m noticing you’re kind of like, your energy is flat, like, I don’t know, you have a good sense of humor and I’m not seeing that as much from you.

I’m seeing the part of you that was very extroverted and liked to connect with people, you’re starting to limit yourself from going out with your friends because of the way you look, and I’m seeing this big, wonderful world that you are a part of gets smaller and smaller.

And when you start with just what you’re observing, it becomes harder for the person to sort of fight against, versus if you start with, “I think you have an eating disorder,” that’s usually not going to be a good approach, it’s just like with addiction, “I think you’re an addict” isn’t going to be a good start to a conversation.

But, I notice you drank 12 beers tonight, that’s a fact, that’s concrete, but also conveying a sense of compassion that you’re not stigmatizing it, you’re not thinking they’re crazy, and trying to meet them at a place of almost trying to understand why you think they’re caught in that.

So, if somebody is, if you’re seeing a loved one who’s engaging in this to say:

“I understand that your health is really important to you, or that being in relationships and wanting to be seen positively by other people, I 100% understand that.”

“I mean, that’s a good value, is to be health-oriented, but, this is not actually filling that value, you might think it’s filling that value, but it’s actually moving you further away from it, because I noticed you’re talking about yourself in more and more negative ways, so I don’t think this is sort of working.”

And sometimes that can help people have some opening to even being able to see somebody, and I would say that to almost present it to them as, you can talk to someone, to even just explore where is this.

And sometimes, maybe you’ll go see the therapist and they’ll tell you, “Oh, yeah, your mom or your dad’s worried too much about things,” parents usually know, but I think it’s important for people to then feel, rather than them being forced to know what they can get out of it in some ways.

So it’s like, well, we can agree that you want to be happier, now, that in and of itself could be helpful for you to see a therapist about, even if that person is at that moment like, and we see this with BDD as well, where someone’s like, “Well, I am not going to accept that I look good, I don’t want someone telling me that I look good when I know I look ugly, I just want plastic surgery.”

But if they can agree, “well, you know you’re getting very upset when you look in the mirror,” so maybe you can talk about even how to calm yourself down in those moments. That can be a lead in sometimes to get people through the door.

Jeff: All great guidance right there, let’s talk a little bit more about social media, you mentioned this earlier, and a viewer has asked for some specific guidance, especially for young people, in terms of navigating social media, what do you suggest they do to not fall into the traps of getting body image issues that become negative through social media?

Roberto: Yeah, it’s a tough one, I mean, honestly it’s like, so I have two teenagers, I have a 17-year-old son and an almost 16-year-old daughter, well, actually almost an 18-year-old son and a 16 year old daughter, and I was pretty strict on the exposure to social media, they actually just recently got some social media.

Now, I know that that isn’t going to work for every kid and with every parent, and some kids sneak behind their parent’s back and doing that, but I was very clear, one, for that reason, and then two, I have ADHD and I know that if I had social media as a kid, it would’ve been a complete distraction.

So, helping them understand where my thinking was around this, but if your kid does, so the more you can delay it, the better, is what I would say, because I think with, I treat kids 12, 13 and they’re getting this endless, endless, endless stream.

And I also want to point out too, that there’s this term body positivity that’s also out there where you might get exposure, let’s say, to people like the singer Lizzo, for example, who’s in a larger body and she’ll post, she’ll have Instagram posts of her in bikinis saying, “Love your body, celebrate your body.”

And although the messaging behind that is great, like we don’t want anyone to feel shame or discriminated against on their body, studies are actually showing that even the body positivity posts are correlated with negative body image.

It’s still objectifying the body, like it’s still promoting the sense that your body is the core sense of who you are, as opposed to how you sing, and your sense of humor, and whether you’re good at building models and those sorts of things, so even with body positivity, there’s that fine line of still conveying this message that the body, the body, the body.

So if your kid does have social media, ask to look at it with them, and ask them, firstly, what kind of content they’re looking at, ‘cause sometimes they might not necessarily be seeing sort of these heavy body image lead in content, but a lot of these influencers will market and advertise products that are related to body image.

I mean, there’s a lot of horrible information, ‘cause influencers have credibility with young people, and honestly, that is equivalent to medical professionals, if not more so.

I’ve had young people I work with who will listen to what an Instagram influencer, who has no credentials, says over what I might say, and I have to convince them that they’re actually wrong, that that information is not correct, it is not healthy to use x, y, z product, especially when you’re 13 years old.

So be aware of what the content is, talk to them about that, and what’s also important is not about necessarily blaming them for liking it, I frankly, I totally and completely understand why, especially young people, are hooked on social media, I get it, and so we don’t want to say, “Oh, that’s like garbage, why are you,” as if it’s your child’s problem that they’re hooked on it.

These apps are designed to have people hooked on them, they’re designed that way, I mean, there’s a whole team of people that are like, how do we get people staying on this, having boundaries and guidelines of how often they can be on it, making sure they’re doing other things, except just looking at constant TikTok videos.

Jeff: Before we let you go, we’d be remiss not to ask you about eating disorders with boys and men, because this is an area that you specialize in. And a viewer asks, what are some of the differences in diagnosing and treating eating disorders when we’re talking about the male gender?

Roberto: Yes, so this is something I’ve specialized in for 30 years and doing research with boys and men with eating disorders, which are vastly underdiagnosed, and we know that if less than 10% of women and girls are getting treatment for eating disorders, it’s even far less for boys and men.

In some ways they can present very similarly as with girls and women, but in other ways it can present differently, and studies actually show that there’s an implicit bias in even medical and mental health communities of underdiagnosing these issues.

Like, there was a study that showed, it had a case study of a girl, a female patient with certain symptoms that were suggestive of an eating disorder, and a case study where all they switched was the name of the person, from a girl’s name to a boy’s name.

It was with medical doctors and primary care physicians, and the primary care physicians were more likely to say, “Oh, I think it’s eating disorders,” when it was a girl, and less likely to do that with the boy. And so we know that there’s a lot of under-recognition.

With boys though, even with anorexia, I would say in general it’s less, I have worked with boys where they want to be skinny and thin and they use that language, most of the boys I’ve worked with, with anorexia, do not use that language, they want to be lean, which is different than being skinny.

And so with boys, muscularity plays a very important role for many boys, not all, but many boys and men in their body image, so they’re trying to be lean, but have muscle, and you have to have body fat in order to create muscle.

And so that’s often the pursuit, so even with boys with anorexia, you’ll often see that they have less distortions, they know that, a lot of the boys I’ve worked with who are in that position.

They know that they’re very skinny, that they know this is emaciated and they don’t want to look that way, but they fear eating, a lot of boys will say to me, “If you can guarantee what I eat turns into muscle and not fat, I would’ve no problem eating it.”

That’s a very different mentality, that for girls where being overweight and over fat are the same thing, for boys, like if you look at bodybuilders, many of them are technically overweight, but they’re not over body fat, I mean, they have very small like levels of body fat.

Binge eating episodes, you’ll tend to see sort of more volume of eating, you’ll have higher rates of substance abuse amongst males with eating disorders, and a lot of sort of fears sometimes of like maturity, and particularly with anorexia, and a lot of shame.

I would say that’s probably the biggest part of when I first start working with males that is really addressing the shame that this is not, there is no disorder condition that’s like for women only, for men only, that this is, it’s a disorder, it’s an issue that we need treatment, that you need treatment for.

And that’s a lot, the good news though, Jeff, is I would say it’s with younger people, it’s becoming a little less stigmatized, and that could be the upside of social media, there are some upsides to it, where there is some destigmatization around having a therapist.

Even, like many young people I work with tell their other friends, “Oh yeah, my therapist Dr. Ro,” and that didn’t happen 20 years ago, like it was almost like going to therapy was like, this sort of shameful thing, and that is nice to see.

With the older guys that I work with, there’s still a lot of shame about having eating disorders, having body dysmorphic disorder, this sort of equivalence that only women struggle with these issues, or only people, gay men struggle with these issues.

And I work with gay men who have these issues, and I work with men who don’t identify as gay that have these issues, that sexuality is not a contributing factor, but if that’s part of the picture, then that becomes sort of part of the profile.

Jeff: You are a very positive guy, which is something I very much like about your approach to treatment, let’s wrap this up on a positive note here, you’ve talked several times about the hope that’s available through treatment, let’s just wrap up with that.

Roberto: 100% that that’s the main, main takeaway I want people to get is that these disorders can feel hopeless and people can feel very defeated.

Recovery is absolutely possible, and it’s about just getting the right professionals on board, it will be work, but it will be worth it. I’ve never worked with someone who has recovered from an eating disorder and said, “Ugh, I wish I didn’t go through all that.”

They feel just liberated from it, and in fact, they realize that the illusion of the eating disorder is like, that I needed the eating disorder in order to feel in control, to feel better, to be liked, and they realized that’s not true at all.

In fact, that was the opposite, they can be in their bodies, I mean, to be present, be connected, to enjoy things, we have to be physically and mentally in our bodies, and that’s what recovery looks like, and it’s a sweet world of recovery.

Jeff: And I think that’s a perfect place to wrap this up for today, Roberto, thanks as always for joining us today, you are a wealth of knowledge and we really very much appreciate your sharing that knowledge with us.

Roberto: Oh, my pleasure, Jeff, always, always a pleasure.

Jeff: We’ll see you again soon, Roberto Olivardia, and I want to thank all of you who have tuned in today on behalf of McLean Hospital, we hope to see you again soon, have a wonderful day.

Jenn: Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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