“I Wish I Had a Little Bit of Anorexia” and Other Misconceptions: A Candid Conversation with Dr. Steven F. Crawford of Sheppard Pratt

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Dr. Crawford headshot

Prompted by this reporter, Dr. Steven F. Crawford — the associate director of the Center for Eating Disorders at Sheppard Pratt — rattles off a few common misconceptions about eating disorders. He riffs. In fact, he’s very creative in his responses.

“I wish I had a little bit of anorexia,” Crawford says. “Eating disorders are a lifestyle choice; you can tell if someone has an eating disorder by looking at them; eating disorders are a young girl’s disease; eating disorders are a passing phase in someone’s life and it is best to ignore [them]; eating disorders are caused by photographs of skinny models; the family causes someone to have an eating disorder…”

He could easily continue but pauses so I can catch up.

For more than two decades, Crawford has studied and treated people with all manner of complex eating diseases, including anorexia nervosa, bulimia nervosa, and binge eating. A Baltimore native, the doctor also serves on the faculty of the University of Maryland School of Medicine — his 1986 med-school alma mater — where he teaches students and trainees how to identify these disorders.

Crawford says he was in the right place at the right time to gain entrée into a growing field focused on deadly dieting and overconsumption, a difficult field he calls “fascinating.” Fascinating because these serious eating diseases can absolutely halt patients from reaching their potential in life, he tells me. Meanwhile, expert therapy can often save them. And he’s obsessed with saving people.

“The fourth year of my Psychiatry residency training program was an elective year and it was the same year that Harry Brandt, M.D., was recruited from being the Chief of the Eating Disorders Unit at the National Institute of Mental Health to open an eating disorders program at a local hospital in Baltimore.  I was fortunate to be selected to be a fellow for this eating disorder program,” Crawford says. “I was always interested in the interplay between psychiatric illness and physical health, and with eating disorders this is clearly a major concern. The interplay of biological, psychological and social issues is a key factor in the development of these illnesses.”

The lauded Center for Eating Disorders at Sheppard Pratt offers inpatient, day hospital and intensive outpatient programming.

In honor of Eating Disorders Awareness Week, which begins today and runs through March 4th, I talked to Crawford about his nitty-gritty analysis of and informed instincts about eating disorders: What do we fail to understand as a culture? How much is society to blame? How often are men held hostage by eating disorders? Which age groups are most prone to contract them? And more hardball questions, for which he provided expansive answers. Go online to learn more about Sheppard Pratt and the education week. http://www.eatingdisorder.org

What is the single biggest misconception (or misunderstanding) about eating disorders?

There are so many misconceptions about eating disorders it is hard to pick just one.  The truth is that eating disorders are 50 to 80 percent biologically/genetically determined and these factors make an individual vulnerable to develop an eating disorder. The other environmental factors (bullying, diet pressures, media, trauma, etc.) may then come into play with the underlying genetics in such a way that the vulnerable individual develops an eating disorder.

Eating disorders do not discriminate. They affect young, middle aged, and old. They affect all socio-economic groups, all ethnicities, men and women. And you certainly cannot tell by looking at someone if they have an eating disorder or not. Individuals with eating disorders come in all sizes and shapes.

Finally, anyone understanding this illness would never wish they had even a little bit of it. It is a devastating illness that creates a lot of pain and suffering for an individual. It has the highest mortality rate of any psychiatric illness. No one would choose this path and it is no one’s fault when it occurs. It is best to focus on the future and the path to recovery when faced with an eating disorder.

Roughly how many people in the U.S. suffer from an eating disorder? Why do you think the problem is so significant right now?

The number of individuals with anorexia, bulimia, binge eating disorder, and other eating disorders has increased significantly over the past 30 years. Currently, it is estimated that approximately 30 million people suffer from some form of an eating disorder, of which 10 million are men. Additionally, at any given time, 10 percent or more of late adolescent and adult women report disordered eating behaviors. Although these behaviors may not satisfy full diagnostic criteria for an eating disorder, they do often cause distress and impairment in a person’s life.

It is difficult to point to one factor stimulating the increase in numbers of individuals impacted by an eating disorder. Perhaps one factor to consider is the current “war on obesity” which may be fueling an already pervasive fear of fat in children, and is inadvertently promoting disordered eating behaviors.

How should our culture strive to evolve so that eating disorders are less of an issue?

A change in several key elements in our culture might help to lessen the growing numbers of individuals afflicted with eating disorders. First and foremost, a shift in the focus from weight to health could promote an understanding that health is determined by more than the number on the scale. If weight loss is perceived as the means to health, people may adopt unhealthy behaviors to get to the goal. If lifestyle choices such as engaging in activities that you enjoy — and happen to get you moving — is seen as the goal, people may actually make lifelong changes for the better.

Second, addressing the grocery store deserts in major metropolitan areas and making all food choices as affordable as fast food would go a long way in changing our society’s relationship with food.

Finally, promoting diversity in our advertising/media world with positive role models of people of all sizes and shapes could help our children to learn size- and self-acceptance.

What is the average age of people who suffer from eating disorders? Is it true that women in their 40’s are falling victim more often? If so, why?

The age range for individuals with eating disorders has greatly expanded in recent years. The latest statistics provided by The National Eating Disorders Association (2011) indicate that by the age of six, children already begin to express concerns about their own weight or shape. The American Academy of Pediatrics also reports that hospitalizations for eating disorders in children eight to 12 years old increased 119 percent between 1999 and 2006.

Recent studies have also highlighted growing numbers in women aged 40 and up. One recent study found that as many as 13 percent of women over the age of 50 have eating disorders. There are many possible reasons for this development. First, it is a time of major life transition with children moving out of the home and the “empty nest syndrome.” Additionally, the media continues to extend pressure on every generation to look younger, repeatedly discouraging the baby boomers from aging. We constantly see headlines touting that 40 is the new 30; 50 is the new 40; 60…

Most often the spotlight is on women, but men suffer from eating disorders too, in staggering numbers, as you’ve explained. Do they experience similar psychological issues? Is treatment for men as easily accessible in our society? 

Historically it has always been identified that the ratio of women to men with eating disorders is 10 to 1.  However, it is currently believed that this is a reflection of the numbers of individuals that present for treatment and not the actual numbers suffering with the illness. Men, particularly in the past, may have been less willing to seek treatment due to increased stigma related to the stereotype that eating disorders are a female disease. Clearly, there are significantly greater numbers of men with eating disorders than originally believed and the numbers do seem to be on the rise. Luckily, more men are speaking out about their experience, which may make it easier for others to seek treatment and know they aren’t alone.

Additionally, with the explosion in the number of men’s health magazines, there is significantly more pressure on men to obtain a certain body type that has dramatically increased the focus for males on their weight and appearance. This may also be playing a role.

Do you believe that people with eating disorders are more likely to have OCD tendencies? What kind of brain is inclined to nurture and cultivate an advanced eating disorder?

Eating disorders tend to have a high co-morbidity, that is, they tend not to occur alone but rather concurrently with other illnesses. Individuals with eating disorders also frequently struggle with mood disorders (as many as 50 percent), anxiety disorders (individuals with anorexia being more obsessional and harm-avoidant), and substance use disorders.

Studies have identified the thinking process of individuals with anorexia nervosa to be extremely detail focused and less flexible than others. This could help to explain how someone focused on achieving health through weight loss could end up restricting their intake to a point where they are literally starving. The focus becomes the weight loss and the bigger picture of health can be lost.

How often can such a health problem be solved successfully? Is it ever cured? 

In general, one-third of individuals are able to sustain a symptom-free lifestyle. Another third will be able to manage their symptoms with either a significant lessening of symptoms or having symptom-free spans of time with periodic relapses. There is a final third of individuals who seem to struggle in an ongoing way and require a significant amount of support and intervention throughout their lives.

The question of whether or not eating disorders can be cured is a current debate in the professional world. I have anecdotally seen both: Some individuals describe a sense that they have moved on in their lives, and that the person they were when they were suffering seems foreign to them and they cannot imagine ever going back. Others indicate that every day they need to make a conscious decision to continue their recovery. The ease with which they are able to make that decision may fluctuate throughout their lives.

The earlier an individual gets into treatment the better their chances for recovery. However, it is important for individuals, whether they are experiencing the illness early or have had the illness for many years, to recognize that recovery is possible and that there is hope!




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