Director, Eating Disorders Program
The Johns Hopkins Hospital
The Stephen and Jean Robinson Associate Professor of Psychiatry
Department of Psychiatry and Behavioral Sciences
You might say Angela Guarda took a path less traveled to psychiatry.
She studied molecular biology as an undergraduate at Johns Hopkins but found it too far removed from understanding the whole person. Then, a psychology elective piqued her interest. She enrolled in a graduate program in psychology but it included too little basic science for her taste, so she quit to take a position as a laboratory technician in Joseph Coyle’s neuroscience lab at Johns Hopkins.
“I kept flip-flopping between molecular science and humanism,” she laughs, “which culminated with getting rejected from acupuncture school and then deciding to apply to medical school.”
Finally, in psychiatry, she found her perfect balance. “Psychiatry encapsulates what it is to be human—understanding what drives our behavior, thoughts and feelings,” Guarda says. “Practicing psychiatry is a privilege. It allows a glimpse into people’s lives and experiences, an opportunity I don’t think is possible in many other fields. And it’s a very rewarding specialty, especially so because the vast majority of patients benefit from treatment.”
As a psychiatry resident at Johns Hopkins, Guarda enjoyed working with young female patients and became interested in anorexia nervosa—a puzzling, often crippling condition with the highest mortality of any psychiatric disorder. She applied to do an exchange program with The Maudsley Hospital in London, working in the eating disorders program under Janet Treasure, one of the field’s best known clinicians and researchers. When she returned, Paul McHugh, then chairman of the psychiatry department, offered her a position as assistant director of the eating disorders program.
The job didn’t come without challenges. It was the mid-1990s, and managed care was rapidly shortening hospital stays and changing the delivery of health care in the U.S. The average inpatient stay on the eating disorders unit for a patient with anorexia nervosa plummeted from three months to six weeks. Guarda was hired to keep the program viable.
A positive development that emerged from these changes in the health care landscape, she says, was the creation of less costly partial hospitalization or day programs for treating eating disorders. At Johns Hopkins, the partial hospitalization and inpatient programs are fully integrated, with treatment provided in the same location by the same treatment team. As patients transition from inpatient to the partial hospitalization program, treatment focus shifts from medical, psychiatric and nutritional stabilization to relapse prevention. Patients prepare and cook meals, go to restaurants and shop for groceries, initially guided by staff and later independently, as their time in the program and clinical supervision decreases.
Throughout treatment, family and group-based behaviorally-focused therapy helps patients reframe and counter negative thoughts and feelings about food and weight and practice healthy coping strategies.
Guarda and the Johns Hopkins program are known for treating medically and psychiatrically complex cases and for the program’s rapid rates of weight restoration for patients with restrictive eating disorders. Faster weight gain means shorter lengths of stay and a higher likelihood of reaching a normal weight by discharge, which is important since reaching a normal weight is the best predictor of recovery from anorexia nervosa. Faster weight gain also decreases the cost and time needed to reach weight restoration, shortening time in the hospital and away from home. All nutrition is meal-based. Despite never using feeding tubes, the program has the highest published rate of weight restoration for anorexia nervosa. Most patients leave Johns Hopkins at a normal weight, able to eat a wide range of foods across a variety of social settings—something they were unable to do without intense anxiety, if at all, prior to admission.
Guarda also conducts research studies. Her clinical research is focused on assessing outcomes of intensive treatment programs and increasing the efficacy of hospital-based treatment. She is also involved in translational research examining biological mechanisms that underlie the driven nature of eating disorders. This work includes neuroimaging studies assessing brain activation in appetitive, reward and anxiety-related neural circuits in response to food stimuli in patients with anorexia nervosa.
Guarda says the greatest personal satisfaction she gets is bearing witness to her patients’ progress: “I have treated many patients with life-threatening anorexia who are now therapists, nurses, teachers and lawyers, who enjoy full and productive lives, have children and partners…To witness and to be part of their recovery is a privilege and immensely rewarding.”