Bulimia Recovery Expert Interview: James Lock, MD, PhDNov 24, 2023
Last week, I had the great honor of speaking with Dr. James Lock, M.D., PhD. He is the Director of the Stanford Child and Adolescent Eating Disorder Program, Senior Associate Chair for the Department of Psychiatry and Behavioral Sciences, and Professor of Child and Adolescent Psychiatry and Child Development at Stanford University School of Medicine. As a renowned clinician and researcher focusing on the development and treatment of eating disorders in children and adolescents, he has been recognized multiple times by the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry. He is the author of dozens of peer-reviewed publications on eating disorders in adolescence and continues to quite literally “write the book” on treating these mental illnesses. Dr. Lock talked with me about his clinical findings regarding the assessment and treatment of bulimia in adolescents.
Will you walk me through your clinical assessment & diagnosis of someone with bulimia—which behaviors are most concerning for you and how often does the person need to engage in the behaviors to be considered “sick enough” for treatment?
"Okay. Well, to start with, I'm a child and adolescent clinician, so that's important. I see people usually presenting at fifteen, sixteen, and seventeen. So these are middle-aged teenagers. This is important because what you think about as severity or needing intervention might be different for someone who is just developing an illness, and you want to kind of forestall it from getting worse, than someone who has some more chronic presentation or comes in as an adult and has an established pattern.
This would be true across everything in childhood and adolescent mental health. You don't want to have them necessarily meet adult thresholds for disorders because these are kids, and you can potentially intervene effectively. It's one of the problems with the DSM, across the board, really, but it has gotten better over the years of being developmentally sensitive in terms of the criteria. But, with eating disorders, there are things that have changed that are good over the last ten or fifteen years. But still, the diagnostic thresholds are, for the most part, around adult kind of norms. So now to come to your question, what does our evaluation look like? So, our evaluation for kids with eating disorders is pretty much the same across the board. We usually do a two-hour interview, one with the child and one with their parents. And then they would meet with our dietitian to understand from a nutritional point of view what they're doing, and then they would meet with our adolescent medicine doctor. We would do a physical exam and look for any signs of physical impacts of their behaviors, and that would include lab work as part of that. Usually, you'd be looking at electrolytes, for example, hormone levels, and things like that. So that's the basic thing. So it's about six, seven hours of the day. At the end of that, we have a meeting with the family, and just say, okay, here's what we found. In the case of binge eating or bulimia, this is the diagnosis, and here's why, and we explain what the behaviors are and and why they're concerning both emotionally, behaviorally, and physically. And then we recommend treatments. And there are a couple of evidence-based treatments and we would describe those treatments. If we had an opening, we would offer what we could. And if we didn't, we would refer them to people we know that offer these treatments."
Which personality traits & co-occurring mood disorders do you see most often in those with Bulimia?
"Well, that's a really great question, and you're quite right that you see a lot of comorbidity in terms of mental disorders. Depression is the most common that we see. Let me just clarify for a minute- whether they make full criteria for depression is a different question. However, they often meet many criteria for depression and appear depressed. So that's the most common. Why am I being careful about that? Because people who have bulimia often feel very bad about themselves. Their self-esteem is low. They feel like they're not attractive. They feel like they're not socially acceptable, and that makes them feel bad about themselves. So they often seem and look or act depressed. And that's important because whether that's the depression independently or whether it's an effect of actually having bulimia is something that's important. What's interesting, that in regard to that, is if you treat bulimia effectively, whatever method you use, usually depression lifts without a separate kind of treatment. So it suggests that they're running together with the emotional, psychological, and behavioral impacts that bulimia has on a young person to create the appearance of major depression, whereas the one that probably is the leading edge is really bulimia."
My clients often ask if they recover from bulimia, will their OCD, anxiety, etc also go away, or will they always need to manage something?
"Well, my usual answer to that is based on our clinical experience, which is that if you had depression and OCD or ADHD before you develop bulimia, that's probably going to be something you're going to continue to struggle with. If it all comes together with bulimia and you get effective treatment for bulimia, then I think you can be more optimistic that additional treatments for these other kinds of problems won't be needed if they remain remitted from bulimia.
The diagnoses that we work with are not platonic ideals that come down from heaven with clarity. They are descriptives. And so, the obsessional worry that comes from checking things and worrying about 'What did you eat' and 'What am I going to do about it' those sorts of things, they look like OCD, and they feel like it, but they are really related to the preoccupations of bulimia."
We know that not everyone has equal access to high-quality eating disorder specialists or treatment centers, but if you could recommend a specific form of therapy or treatment for bulimia recovery what would it be and why?
"Well, let's just say a couple of things. One is that depends on how old they are. And number two, I wish we knew more about the treatment of bulimia, especially in young people. And with that context, I'll answer your question. In adults with bulimia, I would recommend cognitive behavioral therapy as a first-line treatment, as the most efficient and effective for adults. And why? Because adults manage their own lives, they buy their own groceries, they pack their own kitchens, and their lives are mostly under their schedule and control. But for teenagers, I recommend family-based treatment, and I do that not only because of the developmental reasons, that is that they're living at home with their families. But we actually studied it. We published a clinical trial comparing FBT to CBT, and FBT was faster and more effective. So that science supports that developmentally sensitive approach, meaning that if you're living in a family and you have a resource like your parents, whatever mental problem you have, likely they're going to be helpful to you, in most instances. Of course, there are, but you have to say what you say, which is that there are clinical reality sets that affect any treatment, but on average, that's what I would say.
One of the things that I like to say to young people with bulimia is that the shame that goes with the illness and the hiding of it, and the sense of inadequacy, when it's opened up and supported as an illness by parents, the diminishment of those really negative and self-destructive kind of thoughts and feelings really changes everything for the young person in terms of their sense about, 'well, I actually don't have to feel like a failure. I have got an illness, and I'm not a bad person because I have that.' Parents can ameliorate that when they understand it too. At first, they may be very confused because it seems so strange to them. But, once that confusion is overcome, and they can develop empathy for the struggles of their son or daughter with bulimia, that changes so much. It allows help to also be much more used."
In my role as a recovery coach, I help my clients specifically with self-awareness and mindset in an attempt to live more in the present. Will you talk a bit about how you believe psychotherapy & reprogramming our subconscious thoughts work to change the behaviors of someone with bulimia?
“Well, it's an interesting way to think about it. What do I really think happens inside a person who's recovering from bulimia? So, here's how I think it develops. Someone wants to be attractive and they think they will be more attractive if they lose a little weight. And they try to do that, and it doesn't go that well. So they add in, ‘I think I'll just throw up what I ate because I'm hungry.’ So usually the pattern is they don't eat. And then they get hungry, and then they eat too much, and then they throw it up. And then the cycle begins. And then the next day, they say, ‘Oh, I screwed up. I won't do that again. I'm not going to eat all day because I ate too much.’ And then, so this habit element, it doesn't start on the day. One does it once and then twice twice and then it becomes a habit. And the person with bulimia feels stuck with that, meaning that's what you're calling ‘programmed unconscious.’ They're stuck with a behavior and furthermore, at some point, sometimes people, and I don't know if this happened with you, but it happens with many, is that they start using bingeing and purging to manage emotional states. So no longer just for appearance, but now ‘I'm upset with my mom, I am going to go and eat a bunch of food and then feel bad and throw it up.’ And so, it starts off, like, ‘Oh, I wanna manage my weight’ but then it becomes more general. ‘It's something that I manage a lot of my emotions with. I started managing my emotions with it, not just my appearance.’ And when that happens, and you get an immediate relief, that immediate relief of ‘I've done something. I've gotten all this incredible, reward food thing, and then just getting rid of it gives me a different kind of relief.’ And that becomes even stronger reinforcement for the behavior.
So how do you change those reinforcements? How do you, as you put it, ‘reprogram the unconscious,’ I would call it 'how do you change habits that are no longer conscious’ because they don't feel conscious anymore, usually at that stage. You're just stuck with them. But when I'm working with someone with bulimia, that's the thing—accepting that they don't like them, but they're stuck with them. You know, ‘I don't really like doing what I'm doing, but I don't know what else to do.’ It would be kind of one of the ways that I would phrase it. And, furthermore, it's not working, and I'm still stuck with it, which is another kind of piece of it. But because of the stuckness, it's hard to move it. So you have to gradually unstick it and that means changing the behaviors back. And, usually, this starts with ‘re programming’ as you put it from my perspective, starts with what I call thought experiments or actual behavioral experiments that you test, okay, Let's just test this. Let's just eat this one day and see if you feel like bingeing as much. So these little experiments become the same kind of reversal of the habit. And when you start doing that and you rebuild or you undo the old habit and rebuild it, it becomes a more normal way of eating, and the old habits begin to fade.”
Do you believe there is a unique timeline for full recovery in bulimia that is different than other eating disorders?
“Again, you know, I think it all depends on the age and duration. It's not a simple answer, like, oh yes. But for someone who's been bulimic for ten or fifteen, twenty years, I think one has to think very carefully about what the goals of that treatment are initially, and then you can see how to modify them. With a young person who's just developing, say, they just started binging and purging once a week, which wouldn't be the criteria for adults, but if I have a kid that's been bingeing and purging once a week or once a month even, I think that's already enough of a signal that we need to work on this. I wouldn't let that go. It'd be like the kid who gets drunk once every month. I'd say, well okay. Well, when you're fourteen, that's worrying, you know, that shouldn't be happening. So they wouldn't qualify for most alcohol programs, but for the kid, you know, I'd want to step in and have parents step in. It's a little bit of an amendment to that question you asked earlier, so I just wanted to put that in there. But, with younger people, in the study that we did, the treatment lasted about six months. About half of them recovered fully. I mean, they didn't have bulimia anymore, but a whole bunch more got better. So it depends also on what you mean by recovery. In my book, with young people, you really do want to see what you've experienced, which is full recovery.”
Is there anything right now being researched about bulimia that you find particularly promising?
“You know, honestly, I don't. I don't think there's enough focus on adolescent bulimia honestly. Or, at this stage, for example, even though medications aren't particularly useful, they are helpful in some people as an adjunctive method to help them with their bingeing. We haven't done anything on kids though. There has been almost nothing. And we should, we should know whether a medication would be helpful. But we don't. Also, what I'd like to see is a therapy called interpersonal psychotherapy, this has been studied for depression and adolescents and it's been studied in adults with bulimia. And even though it's not as effective in adults as CBT is, it does catch up eventually. It's not been studied in kids with bulimia. And interpersonal psychotherapy is a therapy that looks at relationships and developmental challenges as part of its sort of structure. And those are just so relevant to the lives of people with bulimia. Cognitive behavioral therapy, for example, a lot of kids hate that-keeping food records and diaries, they feel that it is more homework and it interferes. And whereas interpersonal psychotherapy, they see immediately that's relevant. It doesn't work directly on behaviors. It works on relationships as maintaining factors. And so it doesn't blame anybody, but it takes on the perspective of ‘you're growing in this way and how is bulimia fitting into that.' So I would like to see research in interpersonal psychotherapy for bulimia, partly because a lot of psychotherapists know how to do IPT, so it's easier to create access to it. And I would like to see that, because you mentioned early on access is a huge issue for all mental disorders and eating disorders very specifically.”
Do you have any favorite resources for those suffering from bulimia that you would like to share?
“That's a really good question. I don't. I have a book for parents, which covers anorexia and bulimia. But it's not really for the teenager if that's what you mean. Since I'm mostly going to be working with families, I think of it as a family. So this is a resource for the family. Help Your Teenager Beat an Eating Disorder covers bulimia as well as anorexia. And, there is a treatment manual for bulimia. But for the family, that's what I would recommend. Again, the clinical case material in that book helps parents understand, and they can actually discuss that with their teenage daughter or son, and say, ‘How does this fit you or not fit you.’ And, when you see it like ‘Oh, I actually do have an illness. I'm not a failure, me as a person. I actually have an illness now. Maybe I started off making a mistake, but it's become something now that's an illness, and I need to participate and just like I would for any illness, I need to take my medicine. I need to do what I need to do to recover but I have an illness.’"
Finally—if there is one bit of advice you could offer to those suffering from bulimia or to the families who love them—what would it be?
“Well, I think we've covered it in many ways. It's to understand that no one’s to blame for this. And that everyone feels stuck and trapped. And try not to be angry or frustrated, but instead kind and supportive. Helping someone understand that they're not a bad person- diminish shame is really the key message, I would say, both internalized shame that you bring to yourself and any shame that's coming from others.”
Author: Merrit Elizabeth, CCI Certified Eating Disorder Recovery Coach
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