Eating Disorders are very complex and have by far, the highest mortality of any psychiatric illness. However, with proper treatment the prognosis for recovery is very good. In fact, I tell my patients that not only can you get better, but you can become a more adaptive, more appreciative person because of your struggles.
The two main eating disorders are anorexia nervosa and bulimia nervosa. Anorexia most frequently presents during adolescence to young adulthood. Up to 20% are male. Onset is often during a stressful life event. There are biological, psychological and sociological factors.
Certain individuals are biologically more programmed to think obsessively. Obsessive thinking coated with anxiety can lead to excessive worrying about difficult life events. If a person going through these events feel that they have no control over them (for example a parental divorce, a geographical move, an illness in the family) they may unconsciously gravitate to the one thing that they think they have 100% control over: what they put in their body.
That makes them feel that they are in control. Weighing their food, eating exactly the same thing each day, food rituals and watching their weight go down gives the person a feeling that they are in control of their world despite the problems happening around them. Of course, this only serves to take them more out of control.
Eating Disorders are not about eating. Sure, that is the superficial layer and we certainly have to pay attention to nutritional status but the underlying problem is not simply, “I want to be thin.” It is a coping mechanism. It involves a struggle to feel in control when they perceive they are out of control.
It also can be a way of numbing feelings. If a person with anorexia obsesses all day about food and weight, they don’t have to think about their other problems.
Sometimes it is a fear of growing up and living life as a responsible adult. Perfectionism can be a key idea. If one becomes a responsible adult, mistakes might happen, and mistakes are not allowed. In the desire for a perfect world, anorexia gives the illusion of a safer place. Eating the exact types and amount of food each day and having the numbers on the scale go down, gives a certainty about life that is calming to one with an eating disorder. Change and risk are not allowed.
Taking chances and risks (which we all have to do in life) is the enemy. Uncertainty is the enemy. The ability to forego food and not have to eat like other people do, is a sign of strength. Passing out from malnutrition, could be a wake-up call or unfortunately, could be taken as a sign that, “I am really good at my eating disorder. I’m doing it right.”
Hence, common statements are, “I’m not sick enough yet. Let me lose some more
weight and then I’ll come for treatment.” “If I give up my eating disorder, who would I be? It’s the only thing I’m good at.”
When one talks like this in group therapy, I always ask the group, “How do we know who is best at their eating disorder?” Without fail, someone shouts out the correct answer: “The dead one.”
So, we have to challenge the anorexic mind-set. You can’t be perfect. You don’t have to be perfect. It is ok to not be perfect and it is impossible to be perfect. Not only are you allowed to make mistakes, but making mistakes can be advantageous. When do we learn more: when we do it right, or when we mess it up? If I fail at something, that does not make me a failure. If I am not allowed to fail, then I better not try. Or, as I would repeatedly tell my kids at little league, “it is ok to strike out. It is not ok to never swing the bat!”
These are some of the common concepts that come up in therapy. The general idea is to increase self-esteem and to increase one’s confidence to go into the unknown. (i.e. life)
The hard work of therapy cannot happen without proper nutrition. One obviously cannot use their higher cortical functions of reason and judgement if they are malnourished. Therefore, the first step is weight gain and stopping the symptoms such as restricting and purging. If weight can’t be restored outpatient, then it has to happen inpatient. Doing outpatient work with the patient being significantly underweight is unlikely to get results and could be dangerous.
If one gets dehydrated, or is using laxatives and vomiting, the potassium could get depleted. Potassium is involved with muscle contraction. Obviously, the muscle we are most concerned with is the heart. If the potassium gets too low, one is at risk for a heart attack. While low potassium is an indication for an immediate medical evaluation, normal blood work is not necessarily a sign that everything is ok. The body has ample reserve capacity that can keep vital systems working, even when symptoms are high. But once that reserve capacity is used up, it can be downhill quickly. Therefore, the symptom picture is more indicative of what we should do, not the fact that the blood work is normal.
Malnutrition, by affecting estrogen levels, can cause absence of the menstrual period. Over-exercise can cause this, too. If this is allowed to continue, the risk of irreversible osteoporosis rises. Oral contraceptives should not be used. They will bring back the period, but will not decrease the risk of osteoporosis. Only weight gain will do that. A bone density test will determine if osteoporosis or osteopenia (an earlier stage of decreased bone density) is present.
Absence of period is especially concerning with an adolescent. New bone tissue is being formed during this time and if the process
is missed, it can’t be made up later.
Then of course is the psychological effect. It can be very discouraging to stay in outpatient treatment and not get any results. With Inpatient treatment, the patient can get over the hump and feel more hopeful that recovery is possible.
With bulimia nervosa, weight can be normal, underweight or overweight. There will be consumption of large amounts of food (binging) with a feeling of no control when one is eating. Then there will be compensatory behaviors to “undo” the binging. These behaviors could be vomiting, laxative use or over exercise.
Patients frequently cycle back and forth between an anorexic picture (that can also include purging) and a bulimic presentation. Restricting leads to binging and binging leads to restricting. Following your meal plan can help prevent both!
Inpatient is usually not needed for bulimia, however if the symptoms are on a daily basis, a short inpatient stay to break the cycle can be extremely helpful.
Although medications don’t treat the eating disorder directly, they can often help with associated symptoms. For example, depression and anxiety are likely to coexist with eating disorders and need to be treated.
Eating disorders can be viewed as OCD-spectrum illnesses and therefore the SSRI’s, which are used to treat OCD, can be helpful in reducing the urges to purge. Vyvanse, a stimulant used to treat ADHD, can decrease urges to binge, but must be used cautiously as it can cause a decrease in appetite.
The mainstay of eating disorder treatment is psychotherapy and weight restoration, including family therapy, which is a very important piece of the treatment plan.
Unfortunately, eating disorders usually do not get better quickly. It is a journey, to be sure. If inpatient treatment is required, it is crucial that it is followed by appropriate outpatient treatment, which should be setup before inpatient discharge so there will be no interruption in treatment.
With perseverance, recovery is likely. Think of it as a long course of outpatient treatment (several years), perhaps punctuated by occasional detours to a higher level of care. Treatment sometimes is less involved, but my point is that patients do get better, even when it seems like things are falling apart. Support groups for family members can be very helpful to hear this message from families who have been there.
For more help on finding treatment programs, support groups and other information, The National Eating Disorder Association is a good source.
I’ve missed more than 9,000 shots in my career. I’ve lost almost 300 games. 26 times, I’ve been trusted to take the game winning shot and missed. I’ve failed over and over and over again in my life. And that is why I succeed.
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