The Art of using Medications in the Treatment of Eating Disorders
When I was an undergrad student, someone told me,“If you want to prescribe medicine, go to med school. If you want to do talk therapy, go to grad school.” At the time, I was deciding on the next step towards a career in mental health. That advice has always seemed too black and white. A mentor suggested that I would not regret the choice of medical school as a vital exposure to the fragility of life and death. Although this is another “black and white” sentiment, it has nonetheless remained with me to this day.
The path of psychiatry is a long road. During the first two years of medical school, the building blocks of anatomy, biochemistry, genetics, and neuroscience are introduced, like prime colors on a palette. We are taught the pathology of the body and mind, a spectrum of illnesses. In pharmacology, medication treatments are catalogued and their pharmacodynamics, dosing, side effects, interactions, and more are memorized. In the third and fourth years of medical school, we are exposed to in vivo medicine with full time rotations in clinical settings, opportunities to envision the big picture of all these foundational parts.
Psychiatry residency is a further four years of specialized training. As a resident, we finally carry the title “doctor,” yet continue with didactics, clinical training, and supervision. Not only do we learn psychopathology and medical treatments, but we also practice the art of communication with patients. Gabbard and Kay (2001) maintain that psychiatrists’ knowledge “allows them to think about patients from the dual perspective of both biology and psychology in all clinical encounters.” Gabbard and Kay also cite social scientist Luhrmann’s observation: “When medications take the place of relationships, not only do patients suffer the side effects of aggressive medication, but they lose the healing power of the relationship. Training in psychotherapy teaches the doctor something that becomes relevant to all encounters with patients, which is the importance of the relationship between doctor and patient and the importance of understanding that relationship in some depth. That relationship can be integral to a patient’s ability to respond to treatment, to feel comforted, to trust a doctor and so to take the medication he prescribes, to feel that if the voices become violent and disturbing there is a safe place to go for care.” (p. 256)
As a psychiatrist and Certified Eating Disorder Specialist, I apply the art of therapeutically delivered medicine on a daily basis. This requires vision of both the patient’s psychopathology as well as psychodynamic influences. Skills work with motivation (see Vansteenkiste et al., 2005 and Mansour et al., 2012), values, dialectics, and cognitive-behavioral strategies are necessary, however this article focuses on the artistic subtleties of prescribing medications. Here are some ideas that I have gathered over the years from supervisors, peers, and my patients.
The canvas/blank slate
A patient’s canvas has already been painted on by the world even before they step into my office. DSM 5 diagnoses can be made like a stencil that traces symptoms into a recognized form. However, it is important to thoroughly inspect the historical canvas. Consider prior events as a hidden sketch below the patient’s apparent veneer. These underlying layers influence the overlying hues or creates textures the penetrate up to the surface. Similarly, the awareness that the obscured shades or images exists below can create a “knowing without knowing” that the patient navigates. The patient and I together choose which section to work on first, bearing in mind that these layers that exist.
Weighty issues: Choosing the Medium (Medication) and Shading (Titrating)
Despite the DSM 5’s categorical approach, “shades of grey” exist between the boxes of each diagnosis. With patients, I tend to use symptom clusters such as anxiety, depression, mood reactivity, impulsivity, or obsessiveness/rigidity. These symptom clusters can be examined as they relate to the eating disorder or in other contexts. This creates a flexibility to understand the rationale for a medication not only for the eating disorder but also for other areas of struggle.
For many patients, the medium of medications brings an array of beliefs or stigmas. For some, “psychoeducation” brings understanding. For others, the first objective is establishing the patient’s trust in a safe environment to work together. Reassurance that any side effects, especially highly feared weight or appetite changes, will be monitored and if we must, we can erase the board and start again. Sometimes a dot-to-dot or color-by-number approach is helpful to get the patient started (e.g., try the medicine just once or twice over the weekend, and we’ll discuss how it went when we next meet). Medication trial time frames such as three or six months may be a middle ground that they are willing to traverse. By proposing several reasonable medication options, the patient has choice and autonomy in the decision and may be able to take a step more easily.
When it comes to titrating the dose, “start low and go slow” is the best guiding principle for patients to most easily adjust to the medication and minimizes potential side effects. This is especially important as individuals with eating disorders tend to be hypervigilant and easily uncomfortable with any new physical sensations. However, medications may not work as expected if the patient is nutritionally compromised. Nutritional optimization is reinforced to provide the best foundation for trying a medication.
Positive and negative space: The patient, treatment team, supports and environment
Many patients are referred to a psychiatrist at the behest of another team member (e.g., the individual therapist) or a family member. In these situations, it is indispensable to have this collateral information as the patient may be opposed to medication and thus hesitant to fully share their struggles during the consultation. The treatment team can surround and support the patient as the centerpiece, scaffolding the patient as they navigate their environment. The ideal team harmoniously complements each other, supports each other, and works to stay on the same page. Support from the family, peers, or allied health professionals via education, counseling, or daily treatment support is the strongest variable for enhancing medication adherence (Nieuwlaat et al, 2014). This is quite humbling, as it reminds me that the prescription is only the first step. The actual practice of taking the medication is where the real work of the medication happens.
In conclusion, I find these art metaphors as interesting ways to envision the work between a psychiatrist and patient. It is an honor to be entrusted by a patient to work with them in their journey and create a life project of healing, health, and happiness. I am appreciative of my wonderful colleagues in the New York City area as well as my patients who I continue to learn from daily.