Dysregulation,eating disorders and other mishaps

Dysregulation, eating disorders and other mishaps


Through the many years I have worked with patients with eating disorders I have come to examine and understand the problem from different perspectives. Like the old and wise story of the blind men and the elephant, I too got a different view of the “animal” depending on what part of its “body” I got to touch at each particular time. So, some times I saw it as the result of an over controlled childhood, sometimes it was a loss of identity, other times it appeared to be the result of over sexualization and objectification of women living in a chauvinistic society or all of the above and more.

Today, in the midst of an avalanche of bad news like the fiasco on Wall Street, the nightmare of the housing market, the catastrophe of the BP spill I am coming around and looking at the elephant from yet another view point: Self regulation. It has become evident that in becoming the land of plenty, America has also lost its ability to self-regulate. The instant gratification of our yearning for the ever elusive bigger house, bigger car, bigger burger, fancier phone, more oil, more energy and so on has become part of our American identity.

From birth on we are training our kids to seek more and more frequent gratification.
The plethora of toys in the nursery which infants do not need and which are over stimulating, the mountain of toys under the Christmas trees that is equally overwhelming, the surfing of the 150 or so TV channels, the ipods, the phones, the computers, should I keep going? In their wish to please parents have become eager contributors to easily bored, restless and demanding kids.

A part of our brain is wired to seek gratification and pleasure. Every time we do something pleasurable Dopamine is excreted in our brain and it makes us feel like a million dollars. So, we seek more of the good staff. Gamblers know this all too well and every time you get excited with the ding sound of a new e mail message you get your dose of the juice too.

It is our job as parents to “train” this part of our kids’ brain that is blindly seeking pleasure. Gratification should be tempered with moderation and balanced with knowledge of consequences. Rewards should be the consequence of work not an entitlement. This culture of self indulgence, from the unearned BMW at 17 years of age to the no-money down mortgages is the path to destruction. Look at history if you do not believe me. It happened to the Roman Empire.

Eating disorders is another example of our inability to self control and self restrain in a world that offers a dizzying variety of foods. I believe the government has recently recognized the need to help people self regulate by mandating better labeling of foods, better education on mortgages and credit cards. But this is just the beginning, a good step but only a step. Restrain, moderation, and responsibility starts in the cradle.

The rise and fall of ....Humanity

I have been thinking about Greece a lot these days, for obvious reasons, with a range of emotions. But most of all I have been asking a lot of questions, such as:

How did the Birth Stone of Western Civilization become the tombstone of decency?
How did the pursue of the Golden Mean become an uncontrollable decent into moral bankruptcy?
When did Justice, the godess that even all the other gods revered, become an exiled beggar?
How did industriousness turn into unearned entitlement?
When did "know thy self" become mental apathy?
When did moderation become greed?
How did the alchemy of the mind (turning vice into virtue, turning the darkness of ignorance into the bright light of knowledge) become the alchemy of the Stock Market (turning horse manure into "gold")?


This past Easter I stood in Plaka, the ancient market place in Athens, with Acropolis looming mormidable above me, just under the cave where Socrates drunk the poison defeding his principles to its last bitter drop and I wondered with trepidation what the Teacher would have said about his beloved town. I stood at the Lyceum where Aristotle taught that towns will flourish only when kings become philosophers and philosophers kings and I wondered how he would have felt at the sight of Greece now, and I cast my eyes to the ground in shame.


But, does the fallen angel have something to teach the rest of the world? I believe so, maybe even the biggest albeit most bitter lesson of all. I believe world empires, beacons of civilization such as Greece and Rome did not fall because they became too big but because in doing so they lost their moral moorings.


Please tell me what is wrong with this picture: I am walking to the door of Starbuck's, two coffees in my hands, the 14 year old ahead of me opens the door exits and lets it slam in my face while her mother looks on and continues to blabber on her cell phone unperturbed by her daughter's rudeness. My father would have made me go back and apologize and followed it up with a 20 minute discussion about the virtues of politeness, respect and cooperation.


Do you prefer a different picture? Try this one: Two adults fighting about a parking space, yes a parking space, using a language totally inconsistent with that social status their cars and clothing so loudly advertise. A bunch of adolescents 50 feet away egg them on. One screams "kill her, kill her" which is followed by another one's pearl of wisdom " I hope he blows her head off"


One needs to ask: If a 14 year old has no social conscience, if his idea of conflict resolution is: "blow her head off" why would we expect the 30 year old wiz with an MBA from the Ivy League School of Live and let Die have any consideration for the society at large when he skillfully manipulates numbers to sell manure for gold?


What would Washington have to say about His beloved country? I lament the decline of my birth place and I hope that my equally beloved America will not follow the trajectory of Greece and Rome. But, hoping is not enough. We need to be the models, the paragons of morality that our youth needs and deserves. We need to teach, guide and monitor our young. We need
to wake up.

In memoriam

together as a team we navigated the ineffable horrors of your past and survived. We faced the external prejudice and the internal persecution and we prevailed. What we did not anticipate and took us by surprise, like a storm in a clear day, was the cancer that ravaged your body in the course of just a few months.


We sat at your front porch watching the setting sun paint the lake red, or was it my anger for this awful injustice that colored my vision? You told me that you were at peace with the world and God. Our work, our journey was not for nothing that because of what we had accomplished you were leaving this world a Free Person.


I am thankful to you, Carol, for all you have taught me, for your courage facing life and your dignity meeting death. I am thankful for your humor and laughter, and for your caring.
Good night sweet princess, and flights of angels sing thee to thy rest.

Is it better to live a good man in a delusional world or a monster in reality?

This was the question that the protagonist in the movie Shutter Island asked his psychiatrist. It is the same question in one form or another that patients have been asking me for the past 20 years.

We all construct illusions to help us deal with the horrors of our past or present. Illusions are the guardians of sanity. If we were constantly conscious of all the pains and stresses of our lives past and present we would have a mental melt down. Through the eons of evolution our brain has developed many elaborate defenses against the ravages of life from the very complex ones like splitting into different personalities to simpler forms of denial and repression such as forgetting a medical appointment or our mother's birthday or just escaping into computer games, alcohol/drugs or convincing ourself that the lip stick on our husband's shirt collar is just tomato sauce.

So, if illusions are our life saver, why is therapy so infamously trying to punch holes in it?what is all this fuss about Reality? Well, the problem with these gaurdians of sanity is that they are frequently exploited, burnt out and often fall asleep on the job. The fact is that the more you rely on denial and repression the less effective they become. When the pressure of all that has been locked up for years mounts and pounds on the locked doors of consciousness our guardians get overwhelmed and drop the ball. Pandora's box opens: depression, anxiety, phobias, obsessive thoughts not to mention an assortment of physical symptoms exotic enough to stomp the best of our medical profession comes flying out. You see, the tears that the eyes will not shed the body will weep. With the advancements of neuroscience we can now take colorful pictures of the brain when emotions are not handled right and these pictures beat Scorsese's scary scenarios.

Trying to run away from our emotional reality is like trying to outrun a freight train, eventually it is going to catch up with us. A patient told me once that she was so mortified to acknowledge that her husband was just like her father that she had for years blinded herself to her daughter's abuse. Reality finally hit her when her daughter attempted suicide. How is this for a Scorsese movie?

Illusions are often hard to give up and reality unbearable to live with. A therapeutic and supportive environment is often essential to abolishing the walls of illusion. An old saying advises us that if you save someone's life you are now responsible for him. The same goes for illusions: if you take someone's illusions away you better be prepared to give him something equally sustaining in their place. This is what therapy offers people. You see, the question is not whether it is better to live in reality as a monster, but rather whether there are really monsters or just human beings who make mistakes, learn from them and move on with their lives in spite of the horrors of their past and sometimes because of them.

In Defense of antidepressants:culprit or falsely accused?

In 2004 the FDA added a "black box" warning on all antidepressants, advising parents that antidepressants prescribed to children and adolescents may increase suicidal thoughts and or behavior, mind you, the operative words here are "may" and "increase"



Now, here is some interesting news: According to a September 2007 CDC report, from 1990 to 2003 the combined suicide rate for people age 10 to 24 declined from 9.48 to 6.78 per 100,000 persons. But from 2003 to 2004 the rate increased from 6.78 to 7.32 per 100,00 people for the same age group.



Do you see where I am driving at here? Let me elucidate: Another study surveyed non-specialist prescribing physicians(meaning physicians that are not psychiatrist) and found that 91% misunderstood the warning to mean that there was a risk of death associated with antidepressants. This means that physicians stopped prescribing medication to youngsters who would have benefited from it. Parents are less inclined to take their children to psychiatrists and even less inclined to give medication that their doctor is telling them will cause their child to kill himself. According to the above mentioned CDC report suicide rates that had decreased since the advent of antidepressants have risen since the warning was added.



I believe that in this case we have thrown out the baby with the proverbial bath water. What research has unequivocally shown is that a combination of therapy and medication, in cases where medicaiton is necessary, is the most effective approach. Instead of outright rejecting medication for moderately to severely depressed kids and adolescents parents should work closely with their physicians and their psychologists so that they can integrate medication with other treatments that are effective, like psychotherapy. Well documented research and my own professional experience has shown that therapy is as effective as medication and has more permanent results, but there are cases where medication is necessary and life saving at least until therapy has been given time to produce results. So, before we write the final epitaph for antidepressants lets give them another serious and educated look.

I have to let you in before I let you go

I have often been asked by grieving patients and survivors of wrecked relationships how to let the sadness and most of all how to let the lost person go.


Human beings have never been good accepting loss. No matter how explainable the loss is, to one degree or another it is interpreted as a personal affront by some malevolent deity. In Robert Frost's eloquent words:


Ah, when to the heart of man
was ever less than a treason
to go with the drift of things
to yield with a grace to reason,
And bow and accept the end
of a love or a season

Another ubiquitous human trait is that we tend to either canonize or demonize the person lost to us. Dead people tend to automatically attain sainthood status, halo included. Divorced partners tend to acquire horns and tails, good traits and memories forever drowned in a pool of anger and hurt.

The probem with this is that we can not mourn for saints/idols, we can not let them go either. We propitiate, ador, and/or fear idols, we do not let them die. Ex partners who are transformed into avatars of Evil are for ever wedded to us with the bonds of hate.

We have to see the person lost to us as a real person, beauty and warts included, before we let him go. Healthy mourning involves many and conficting feelings: love and hate, affection and anger, relief and yearning, freedom and loneliness, resentment and guilt and many others. We have to experience all of these with regards to the departed.

You see, when we transform someone into a saint we would want to keep this saint around to feel protected by him/her, to feel loved, to feel proud of our roots, to function as a paragon of goodness to which everyone else, including ourselves, will be compared to and more often than not fall short. Most of all by cononizing the departed we avoid the messy feelings like anger and regrets that tend to complicate the image of the person we would like to maintain.

When our divorced partner is made into evil personified the wish for retribution and justice for our hurt ego will keep feeding the anger and blinding us to the fact that more often than not it takes 2 to make a good relationship and the same two to break it. It prevents us from learning from our mistakes and moving on.

A patient with an idealized, or I should say deified image of me, told me once when the subject of ending therapy came up: "why would I ever want to let you go?" He was totally flabbergasted and appaled by the idea that someone would want to take his perfect "mother", omniscient god away from him. Later on in therapy when he learned to have a more substantial and realistic relationship with me he was able to see me as a mere mortal and one day he had an epiphany: " I have to let you in before I can let you go" he said beaming with the excitement of his insight. What he meant was just this: He had to see me as a person, well meaning but with many limitations, before he could let me go. It did not make any sense to him that he would ever want to let go of a god, do you blame him? But when the time comes he will be able to mourn for and let go of the physical me while maintaining the momories of me as a person (good and bad, frustrating and encouraging, often knowledgeable at times clueless) who had an impact in his live.

As the years go by...

The years mercilessly
change
childhood memories begin to
fade
When did I exchange my little red
dress
for the daily work
stress?
Can't we stop this crazy
train
for just one moment to
celebrate
like the time we were
young
when the world was innocent and
fun?


May your new year be filled with fun memories.