History of HDRM
At the time this site was developed in 2011, there was only one science-based treatment modality that was not centred exclusively on psychotherapeutic treatments for those with eating disorders and that was Family Based Treatment, formerly known as the Maudsley Treatment. It originated in the Maudsley Hospital in the UK and centred recovery on food intake because the Minnesota starvation experiment showed that all the mental disturbances that were thought to be inherent to the disorder of restricting eating were actually the result of how a starved brain malfunctions.
I go into more detail on the Minnesota starvation experiment in the Phases of Recovery series on this site. The premise behind FBT is that most of the psychiatric manifestations that come with starvation are resolved if the patient really focuses on refeeding. It was revolutionary in eating disorder treatment. Applying all manner of psychiatric drugs and psychotherapeutic treatment modalities to a starving person when they are refusing to eat had been the dominant treatment approach before Maudsley and it was highly unsuccessful in helping patients realize any kind of improvement or remission.
However, FBT is designed for children and therefore guardians feature prominently in the recovery process. For most people visiting this site, they are adolescents and adults of all ages and so the MinnieMaud was developed (a nod to the Minnesota starvation experiment and the Maudsley protocol as it was known then) to address the gap in treatment beyond FBT.
Eating disorders are defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM) using symptom checklists determine whether someone has one kind of eating disorder or another. The problem with this framing is that they are not distinct conditions and the underlying commonality is that the threat identification system in the brain has misidentified food as a threat.
The MinnieMaud integrated all the research that confirmed those with long standing eating disorders will invariably shift across all symptom checklists that were ostensibly identified as distinct disorders in the DSM. That symptom lability undermines the construct that anorexia nervosa and bulimia nervosa are two distinct conditions, for example. So not only would treatment have to get at the underlying problem that generates all these symptoms and behaviours, but the centrality of refeeding would have to be spelled out to allow for adults to self-administer the recovery process rather than depending upon a guardian to feed them.
MinnieMaud was renamed the Homeodynamic Recovery Method to encompass the unity of one treatment for all symptom clusters (anorexia, bulimia, diabulimia, orthorexia, anorexia athletica, binge eating…); to spell out calorie specific minimum intakes to guide self administration of refeeding; and to reflect further research that all bodies have a homeodynamic state of function wherein body mass index is simply a population-based range of incidence and has no bearing on the individual’s optimal health.
Papers on fatness feature very prominently on this site. In previous versions of this site I deferred to the scientific nomenclature of “obesity” when referencing the publications, but I am done with that now. Fat is one of the largest hormone producing organs in our bodies and the term “obesity” hit the mainstream thanks to a National Institutes of Health committee founded in 1998 for which the lead, Xavier Pi Sunyer, had blatant conflict of interests in the weight loss industry, as did all but one of the other committee members as well. References for this can be found in all the papers listed here. Not many organs in our bodies can expand and contract to respond to the body’s need for modulation, but fat can and does. Obesity is almost exclusively the medicalization of the fat organ wherein correlations are misrepresented as causation. And this medicalization harms what the fat organ is there to do, namely modulate all manner of biological functions that, in particular, limit the damage that external environmental inputs can have on the body as a whole. What this means in plain language is:
You have an inherited weight set point and fat organ size and you can only have a chance at health if you allow your body to exist at that set point (no restriction of intake or expenditure of energy absent adequate intake).
There are no instances in the literature where a specific BMI range has been proven to be healthy. Disease shows up in all bodies at all weights and sizes. And any correlations of particular body sizes and higher incidences of disease never prove causation. You could be above your inherited weight set point because you are ill, or your weight and illness have absolutely nothing to do with each other and something else is afoot.
For emphasis: there are no instances in the literature where fatness is the definitive source of disease.
An important component of HDRM is the rejection of the cultural dogma (yes, it’s cultural in origin as the science is not there to support it even when scientists espouse it as fact) that fat is a unit of storage that must shrunk to a mythical healthy size. It is the most contentious component of HDRM, but only because it is running up against this dogma and not because it lacks for actual published data and evidence.
Can the fat organ malfunction? Of course, just like any other organ, but it can also have the capacity to heal not only itself, but many other organs throughout the body thanks to its phenomenal complexity of hormones that it generates, acting upon everything in the body.
HDRM outright rejects the DSM framing that an eating disorder is defined by body weight. HDRM also rejects that binges require suppression; rather they are simply a symptom of the underlying trigger of the eating disorder (food as a threat) when pushed up against the body’s robust systems designed to survive (the drive to get energy in to the system).
No other treatment modality beyond HDRM defines all symptom expressions of eating disorders as having an underlying commonality: the identification of food as a threat. Nor does any other treatment modality beyond HDRM dismiss that either starting weights or weight increases should be used as markers for the type of treatment needed, or as markers for completing treatment, respectively.
Twelve years later at the writing of this entry and I can say that the tenets of HDRM have not been undermined by any recent published materials that I have come across so far. In fact, evidence continues to align with symptom crossover and further mounts against the construct that those with symptoms of binges should quell the binges:
“Specifically, eating disorders are highly comorbid.., have extremely heterogeneous presentations, and individuals often migrate from one specific eating disorder diagnosis to another. ”
What is lacking in all science-based treatment modalities including HDRM is any progress in uncovering a cure. I don’t know whether a cure is feasible as, at a certain point, perhaps the complexity of it all outstrips our ability to do anything more than what we do today. And while HDRM assuredly has a patient-directed mix and match psychoeducational component whereby patients need to work with the neurobiological intractability of an eating disorder with various brain retraining efforts, I have grave misgivings surrounding the ongoing emphasis of the psychiatric framing of eating disorders. Most treatment modalities are solidly in the world of using that framing to design treatments wherein refeeding is put on the back burner in favour of using psychotropic drugs and psychotherapeutic treatment.
Only FBT and HDRM at present centre refeeding in the recovery process and only FBT has published evidence to indicate 30% of those undergoing treatment reach remission. Even then, the very definition of remission for FBT is still centred on weight stability which is not a marker of energy balance by any stretch of the imagination.
Yes I believe HDRM is one of the best treatment modalities that we have today for adults primarily in community. But it is important for patients embarking on any treatment for an eating disorder to understand the limitations of whatever treatment protocol they choose.
Levinson CA, Cusack C, Brown ML, Smith AR. A network approach can improve eating disorder conceptualization and treatment. Nature reviews psychology. 2022 Jul;1(7):419-30.
