Sadly, working in the eating disorders field, we hear this all of the time.

Why does a serious, life-threatening illness with one of the highest mortality rates of any psychiatric disorder inspire such cachet? We believe that its pseudo-prestige stems in part from the exclusivity of the diagnostic criteria listed in the Diagnostic Statistical Manual of Mental Disorders (DSM), which healthcare professionals use to diagnose psychiatric illnesses. Although the hallmark symptom of anorexia nervosa is low body weight, the majority of individuals who struggle with eating disorders—just like people in the general population—are normal weight or overweight.

While only 1 in 200 adults will struggle with full-blown anorexia nervosa, at least 1 in 20 (including 1 in 10 teen girls) will exhibit key symptoms of one or more of the officially recognized DSM eating disorders— anorexia nervosa, bulimia nervosa, and binge eating disorder. Sadly, most never address the issue because they don’t fully meet the relatively narrow diagnostic criteria. These individuals, suffering immensely, often feel invalidated when they are diagnosed with a subclinical illness described with a perplexing acronym like EDNOS (which stands for Eating Disorder Not Otherwise Specified, in DSM-IV) or OSFED (which stands for Other Specified Feeding and Eating Disorder, in the forthcoming DSM-5). Others who struggle are dismissed completely—they don’t even get an acronym, but suffer silently in the ill-defined limbo of “disordered eating.”

That’s why we wrote Almost Anorexic: to provide hope, help, and validation to those who restrict, binge, purge, or battle poor body image, at whatever number on the scale. Because recent research suggests that anorexic behaviors exist on a continuum with normal, we call this grey area between anorexia nervosa and normal eating almost anorexia. Our book is the fourth in Harvard Medical School’s The Almost Effect™ series, which aims to help the countless people who battle with a subclinical mental illness, which is often just as painful (and sometimes more so!) than a full-blown diagnosis.

While many people with almost anorexia might never go on to develop anorexia nervosa, others will indeed cross over. And those who do will inevitably move through the almost anorexic phase as both a prelude to the full-blown illness and in the aftermath of the disorder.

With proper diagnosis and treatment, full recovery from both almost anorexia and other clinical eating disorders is possible.

About the authors

Psychologist and clinical researcher Jennifer J. Thomas dedicated her career to eating disorders after seeing too many young lives touched by these debilitating illnesses during her teen years as a pre-professional ballet dancer. Throughout her career, she has worked with many patients who have fully recovered.

And Jenni Schaefer is happy to share that she is living example of a full life after completely overcoming an eating disorder. You might know Jenni from her books, Life Without Ed and Goodbye Ed, Hello Me. In therapy, she learned to personify her eating disorder, calling it “Ed” (short for “eating disorder”). Treating her eating disorder like a relationship—rather than an illness or a condition—she ultimately “divorced” Ed.

Do you have an Ed in your head?

Here are some questions to help you determine if you (or your loved one) might struggle with almost anorexia:

• Are you underweight, or does your weight frequently shift due to repeated attempts to drop pounds?
• Do you regularly restrict your food intake by amount or variety?
• Do you eat large amounts of food while feeling out of control?
• Do you try to “make up for” calories consumed (e.g., vomiting, laxatives, diuretics, exercise, fasting)?
• Does negative body image interfere with living your life to the fullest?

The more “yes” responses you provide, the more likely it is that your relationship with food is problematic. But please know that freedom is possible. You (or your loved one) can take steps to make peace with food—whether you struggle with anorexia nervosa or a subclinical variation. As we say in Almost Anorexic, “Don’t settle for barely recovered.”

Many people’s drug use looks more like the occasional marijuana smoker’s. And indeed, apart from issues of legality, this drug use is often not really problematic. These people keep their jobs, don’t damage any family relationships, and just don’t create any waves at all with their drugs. It’s a once in a while thing, and the person could take it or leave it. Really, what’s the problem?

But between this end of the spectrum and the person who is consumed by addiction, there is a broad range of individuals who are almost addicted. These are people whose drug use is causing problems right now. These problems may be noticeable in strained relationships, decreased motivation, lackluster job performance or simply not being a fully engaged partner or parent. However, neither the actual drug use nor the problems stemming from it really rise to the level that a medical professional could easily make a diagnosis.

In my book, Almost Addicted, I offer strategies for recognizing “subclinical” addiction – either in yourself or loved ones – as well as a path forward, a road that leads to health and wellness.

Drug use of any sort carries a major stigma in the eyes of many folks. But it’s important to offer people who are using drugs—whether regularly or not–help, support and encouragement.

In Almost Addicted, and in my daily job as a psychiatrist who works in the addiction field, I approach drug use as a problem that needs to be addressed, metaphorically (and sometimes literally), by rolling up my sleeves and going to work.

People who use drugs and enjoy their effects may have trouble acknowledging that there might be more costs to even “casual” drug use than they would like to admit:

• Maybe their grades have fallen
• Or a few friends have walked away.
• Or they made a couple of bad decisions while under the influence.

There are lots of reasons why it’s a good idea for those who are almost addicted to make a change. If you know someone who is struggling a bit, reaching out and supporting that person may help not only him (or her) but also you and many others.

Because of the many relationship connections that we all have, supporting and nurturing those who are in pain (who sometimes might not even be aware they’re in pain) makes the world a better place for everyone. It speaks to a generosity of spirit that represents the best aspects of humanity.

This is a thoroughly researched article (read: “long, but well worth the time”) that nicely explains current thinking on psychopathy before addressing a variety of theories as to why diagnosed psychopaths may not be morally answerable for their crimes (for example, they can’t understand, and therefore be guided by, moral reasons).  Levy essentially accepts that proposition (that psychopaths are not morally responsible for their crimes), but breaks with those who also adopt this same position and reason that psychopaths should, therefore, not be criminally punished.  In Levy’s view, criminal responsibility does not flow from moral responsibility.  To him, they are separate (although often overlapping) issues.

I find his reasoning about criminal responsibility to be compelling (although I’m not as sure about his view on preventive detention), but I am predisposed to that feeling.  The longer I’m involved in the “criminal justice system” the more I come to believe it is not about “justice” at all; it’s simply about rules and whether those rules were knowingly violated (and, yes, that definition depends legal nuances like what is meant by “knowing”, but it’s still a ways from notions of goodness and principle).  Criminal cases may raise questions of “justice” and “morality”, but these are neither central nor dispositive in the way our legal system operates.  In fact, I sometime think that the U.S. Department of Justice, where I used to work, should be called the U.S. Department of Order.

Is Giffords’ assailant competent to stand trial for murder?  Moreover, is he criminally responsible for his actions?

Jared Lee Loughner, a 23-year-old with a history of bizarre behavior and substance abuse, was indicted on 49 criminal charges in connection with the shootings.  The case has not yet gone to trial, and many people wonder why.  Delays are not unusual in criminal cases. They are especially common in high-profile cases like this, where there is evidence of significant mental illness on the part of the defendant.

As of early February 2012, Mr. Loughner had been found incompetent to stand trial and was confined to a forensic hospital—in an effort to restore him to competency through treatment.  Until a judge determines that he is competent to stand trial, the issue of his guilt or innocence cannot be addressed.

In U.S. courts, “competency to stand trial” (CTST) means that the defendant has to be able to cooperate with his attorney and has to understand that he is charged with a crime, the nature of the crime, the trial process and the roles of the various participants in the trial (e.g. the judge, prosecutor, defense attorney, and jury).  A key question when forensic psychiatrists and psychologists assess CTST is whether the defendant truly lacks the ability to cooperate with his attorney or is faking the inability in order to delay trial.

Many people wonder why we have such a system. Why not just take the person to trial, even if he can’t (or won’t) be able to participate?  The answer: to do so would defeat the purposes of the criminal justice system and would violate its underlying principals of fairness.

Making sure that the defendant is competent to stand trial does several things. First, it helps to insure that the proceedings are accurate, as the defendant arguably has the best information about the alleged events, including his own behavior.  Second, it helps to guarantee a fair trial by making sure that inaccurate information is challenged. This includes the defendant being able to confront witnesses against him, a right guaranteed by the U.S. Constitution.  Third, the integrity and dignity of the legal process would be damaged by trying someone who is unaware of his surroundings or the true nature of the trial process damages. Finally, two of the goals of the criminal justice system are retribution (punishing a person who deserves to be punished and knows why) and deterring the guilty person from committing the same criminal act.  If the defendant is incompetent to stand trial, he will not understand why he is being punished or what he should not do again, and that would defeat both of these goals.

Contrary to the concerns of many, the CTST process does not prevent many people from going to trial.  The standard for CTST is quite low– I have been involved in cases where the defendant has been severely mentally ill but the judge ruled that he was CTST.

What can we expect in Mr. Loughner’s case?  First, if he refuses treatment, the court will have to decide if he can be forced to take medication to help restore his CTST.  With or without treatment, the judge will reassess him periodically to determine if he is competent and can proceed to trial. When and if he is found competent, it is likely that an insanity defense will be used, raising important and often emotional issues regarding criminal responsibility.

Though it’s hard to choose a single case that may be deemed the most interesting, one that is at the top of my list is when I organized and led the team that evaluated former World Heavyweight Boxing Champion Mike Tyson. Tyson had been banned from boxing in Nevada after biting the ear of his opponent, Evander Holyfield, during a bout on June 28, 1997.  He was applying to have his boxing license reinstated by the Nevada Athletic Commission and as part of that process the Commission informed him that he had to undergo an assessment to determine if he had any condition that would prevent him from complying with the rules and regulations of boxing.  The Commission gave Mr. Tyson a choice of three institutions where he could have this done, and he chose to come to the Massachusetts General Hospital, where I organized a team to conduct the evaluation.

That project was interesting, and stressful, because of the time pressures involved, strong public feelings about Mr. Tyson and the event, the media storm around the case, and the ultimately unsuccessful efforts to protect his confidentiality by preventing public release of our report.  We had received numerous calls from the media asking for copies of our report, which we refused.  However, under the state of Nevada’s “sunshine law” all communications sent to state officials had to be made available to the public upon request, including otherwise confidential medical reports.  After discussing this issue with Mr. Tyson, we turned our report over to his attorneys.  They appealed unsuccessfully to the Nevada Supreme Court in an effort to prevent the report from being released publically.   They ultimately submitted the report to the Athletic Commission, so that Mr. Tyson could return to boxing, and we almost immediately found our full report on the Internet.  We testified before the Commission, indicating that we did not believe that he was unable to comply with the sport’s rules and regulations, and they did give Mr. Tyson his license to box in Nevada.

The Tyson case was high profile, and fortunately my work usually doesn’t attract the same degree of media attention or controversy that this one did.  However, all of my cases share a common thread in that they involve the complex, often baffling, but never dull challenge of understanding human behavior and its consequences.

Our panel was authorized by Chief Judge Royce C. Lamberth of the United States District Court for the District of Columbia to review the investigative materials, including the previously sealed psychiatric records of Dr. Ivins, for the purpose of “determining what lessons can be learned…and may be useful in preventing future bioterrorism attacks.”   The panel was given access to the entire investigative file and the investigators themselves.  We submitted our report to Chief Judge Lamberth in August 2010 and he authorized its public release, with redactions of confidential medical information, in March 2011.

Our analysis of the materials revealed that Dr. Ivins had a history of problematic behaviors that should have prevented him from obtaining a security clearance and working in that setting. In the report, we identified a number of problems with the existing biosafety and biosecurity procedures that allowed him, and potentially others who presented security risks, to work with dangerous pathogens in a secure setting.  We offered recommendations for correcting those problems and have since been involved in a number of discussions and presentations addressing issues associated with “insider threats.”

While unique in terms of the events, their consequences, and their implications, the Amerithrax case demonstrates the importance of behavioral health issues in the workplace.  Those issues are a large part of the work that I do, whether they involve threats arising from outside or inside an organization or, more commonly, the overall health, safety and welfare of the workplace.

Depending on how well I know the person, I might respond: “How can you stand working with psychopaths?”  (I know it’s not polite to answer a question with a question, but occasionally it’s worth breaching a rule of etiquette for the appropriate effect.)

“What are you talking about?  I’m a teacher.”  Or a nurse.  Or a plumber.  Or a bus driver.  Or a banker.

“Well”, I say, “Believe it or not, some psychopaths are teachers.”  And nurses.  And plumbers.  And bus drivers.  And bankers.

In fact, experts believe that at least 1 in a 100 people in the general population is a psychopath, and that psychopaths are found in every walk of life.  That’s 1 in a 100 of the people in your town, at your kid’s college, at your wife’s job, in your professional association.  Psychopaths are everywhere.  They are people you love, people you hate, people you’ve known since you were kids, people you just recognize from around.  Of course, that means that almost everyone you know isn’t a psychopath, but it’s extremely likely that you’ve run into a number of them at some point in your life.  Maybe you are even dealing with one now (whether you recognize it or not).

Psychopathy is a psychological condition in which the person shows a profound lack of empathy for the feelings of others, and a willingness to engage in immoral and antisocial behavior for short-term gains.  Psychopaths are also extremely egocentric and quick to use any means, including violence, to get what they want.  They will have a life history chock full of examples of conning, lack of remorse for their inappropriate actions, pathological lying and the like, but they are not all convicted criminals.

Think about that for a minute.  Does that sound like anyone you know?  Or work with?  Or dated?  Live down the block from? Maybe someone your boyfriend told you about from his past? And, as we discuss in our book, it’s likely that a higher percentage of people (anywhere from 5 to 15% of the general population) are what we call Almost Psychopaths, people who display the characteristics of a psychopath to a lesser degree or with less frequency, but who are nonetheless more manipulative, impulsive and dangerous than the average person.

So, I guess the best answer to how I can stand working with psychopaths is that I don’t have a choice.  And really, neither do you.

That is usually met with a blank stare, because while people generally know what the Massachusetts General Hospital is, they are not sure what to make of  “forensic psychiatry program.”  Trying to be helpful (but rarely succeeding) I add, “I’m a forensic psychiatrist.”

In the majority of encounters–including with other physicians—that just gives rise to another question: “What in the world is a forensic psychiatrist?” Sometimes this is asked with a particularly quizzical and troubled look, in which case I’ve probably encountered someone who is thinking of forensic pathology (the work that medical examiners do in performing autopsies as part of investigations, usually in criminal cases, and frequently featured on TV crime shows like CSI). In that case, I know I need to respond quickly: “No, that does not mean that I do psychotherapy with dead people.”   That generally elicits some relief, and keeps people from acting on their urge to check for text messages or get out of the elevator at the next floor, but they still need an answer.

So, here it is. Or at least my version of it.  Forensic psychiatrists are psychiatrists (physicians who complete a four year residency in psychiatry after medical school) who specialize in forensic psychiatry: the application of clinical and scientific aspects of psychiatry to matters that are related to, or are directly involved in, the legal system.  Most forensic psychiatrists spend at least some portion of their time serving as expert witnesses in criminal and civil matters.  In criminal cases, the typical role for forensic psychiatrists involves evaluations of and testimony about the defendant’s competency to stand trial or criminal responsibility—which we’ll discuss in a later blog post.  In civil matters, [among other things,] forensic psychiatrists are asked to evaluate the type and extent of emotional distress damages a person did (or didn’t) experience as a result of an injury.

The amount of time a given forensic psychiatrist spends doing expert witness work varies. Some spend their time almost entirely as clinicians in correctional facilities, treating criminal defendants or convicted criminals who have mental health problems.  Others, like me, spend a good portion of their time consulting to organizations or government agencies on issues ranging from workplace violence, fitness for duty, and mental health issues in the workplace to school shootings and terrorism.

It is important to note that forensic psychology is a related and extremely important discipline.  The definition is essentially the same: the application of the clinical and scientific aspects of psychology to matters that are related to, or are directly involved in, the legal system.  Each field, psychiatry and psychology, brings their own expertise to these problems, and complements the efforts of the other.

As I look over the color coded dates this fall, I was surprised to see that this year’s Harvard – Yale football game at Harvard on November 20th was an amber or moderate risk day.  Somehow, I expected this to be red.  After all, crimson is the school’s color.  Since I live near the Charles River, I was also interested in the amber dates for the Head of the Charles Regatta.  Perhaps I’ve been wrong to assume that all sporting events seem to be soaked in alcohol.  Evidently, other events on the academic calendar carry greater risks.  For example, the fall and spring Harvard Hungama are red dates.  I don’t know the meaning of the word Hungama, but I now know that heavy drinking happens at this event according to the calendar.  The house formals in December and May are green indicating potential risk.  Also, May 15^th to 26^th coincide with the end of exams and commencement and these dates were colored green for potential risk.  I suppose the potential for drinking could go either way with exams: celebrating success or drowning one’s sorrows for failing.

Other colleges and universities probably have similar ways of assessing the periods of high, moderate, and potential risk for drinking in the student population, and if they don’t it would be very helpful to their students if the did so.

Knowing about the relative risk for alcohol related problems extends beyond academia.  State and local police departments typically increase surveillance for drunk drivers during certain holidays.  I read an article in the local newspaper yesterday in which a local bar owner touted the bump in business that the football season brings.  His Sunday business shows a dramatic increase during football season.  A few years ago, the Red Sox won the World Series.  That certainly was cause for celebration, but the free flowing alcohol during and after the game caused a near riot in Boston.  These were avid fans, not down and out alcoholics.  Most drank responsibly throughout their lives, but that night their heavy drinking plus the mob mentality equaled a tragedy in the midst of triumph.  The elated but inebriated crowd became unruly and the situation worsened to the point that the police had to fire tear gas to restore order.  Sadly, a canister accidentally struck and killed a young woman bystander watching the festivities.  The death cannot be blamed on any one individual even though many fans that night were plastered.  I believe that every intoxicated person in that crowd probably deserves some share of the blame.  A little bit of impaired judgment in a lot of people caused the problem.  Therefore, whether your team wins the World Series, the World Cup, or whatever, toast them, but do so responsibly.

In the end, it is the individual, not a college or a cop, who must insure responsible drinking.  Perhaps everyone who drinks should take a moment to consider the particular days of the year, the month, or the week that put them at greatest risk for problem drinking.  Maybe you only drink once a year to deal with Thanksgiving dinner at the in-laws or maybe you only drink at parties.  Knowing when you drink might give insights to why you drink.  Sometimes problem drinking is a symptom of something else, for example, that dismal relationship with your mother-in-law.  In my experience, alcohol hurts relationships more than it helps them, but don’t think that I’m against all drinking.  I’m only against drinking that causes problems—what we call almost alcoholic drinking.

First, decreased inhibitions related to alcohol lead to risky behaviors.  The quiet woman from the secretarial pool who has a few drinks at a party may not be over the legal limit, but she seems to be much more social and sexual innuendos slip into her conversation.  She may not even be aware that she said anything provocative, but her male co-worker assumes that she has taken an interest in him.  He has mistaken her uninhibited behavior with more amorous overtones.  In most cases this scenario may play out with an embarrassing moment; at worst, however, it can lead to a sexual assault.  The latter outcome becomes much more likely if the man has been drinking as well.  We hear about such situations between men and women more commonly, but the same can happen amongst homosexuals or inadvertently between homosexuals and heterosexuals.

I met someone recently who was accused of sexually harassing a female co-ed while he was in college.   In hindsight, he realized that he that he should not have encouraged her to go to a drinking party with him and his friends off campus.  Only later did he realize that she was underage.  Nevertheless, he was charged with sexual assault, which did not make any sense to him.  Since he knew that he was gay from the time he was in grammar school, he assured me that sexual assault or even attraction was not on his mind at the time.  He had been drinking that day, so somehow his impaired judgment certainly made a first impression he definitely regretted.  If alcohol could make this gay young man seems sexually aggressive to a woman, think of the way a straight guy might seem with a little alcohol on board.  Of course, most men who drink do not come across as sexual predators, but statistics show that most sexual assault does involve alcohol in at least one of the individuals involved in this crime.

In the above case, the woman had also been drinking. As it true I many cases of date rape, the victim also shows poor judgment due to drinking.  That does not justify the rape, but it does represent a complicating factor, as alcohol lowers inhibitions and may make a woman seem more interested in a sexual encounter than she intends.  A little impaired judgment on her part combined with a bit of misinterpretation by the guy can equal an unfortunate sexual encounter that might haunt both parties once they are sober.

In a worse case scenario, one person might become so intoxicated that he or she no longer has the capacity to exercise any sort of judgment.  They may pass out and may not even be aware that someone had intercourse with them until it is too late.   However, the law is clear from recent court decisions: It protects a person who is too incapacitated from alcohol to give consent or resist a sexual advance.  Like a bartender who becomes culpable if he continues to serve a person who is too drunk to drive, having sex with someone who is too intoxicated to resist is considered a crime.  On the other hand, the legal code does not condone sexually aggressive behaviors by someone who is drunk.  The bottom line is that our courts rightly protect victims, even if they are intoxicated, and intoxication is a feeble excuse for anyone charged with sexual assault in the eyes of the law. That said, drinking more than one intends represents a definite risk factor.