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Wednesday 18 July 2012

What every doctor should know:

An eating disorder is a physiological and a psychological disorder.  

Regarding an eating disorder as a purely psychological problem and treating it as such can prolong and perpetuate the disorder.  Treating the purely physiological symptoms by refeeding to 90% of an Ideal Body Weight ("IBW"), without addressing an aftercare plan, continued weight gain, help with anxiety, etc. is like throwing a drowning man back in the water.

Refeeding an anorexic or normalising nutrition for someone with bulimia or BED is the first step to enable them to start to recover.  Talking about it doesn't repair the malnutrition or repair the physical damage to the body and the brain.  By the same token, just refeeding without exploring therapeutic avenues and being aware of co-morbid conditions often lead to relapse.

It should be noted that therapy is more effective once the patient's weight is nearing its normal range.

You don't have to be thin to have an eating disorder.

You don't.  Nor do you have to be fat.  You can be of quite normal weight.  If your patient presents at a normal weight, be thankful.  This gives you a chance to intervene early.  Early intervention produces better results in the majority of cases.  Be brave.  Just because the DSM says you have to be "thin" to have Anorexia Nervosa, use your gumption and start treatment before your patient is seriously malnourished.

There is a myth that Bulimia Nervosa is somehow not so "serious".  Not true.  

BED patients are at serious risk from  for type 2 diabetes, high blood pressure (hypertension), high blood cholesterol levels (hypercholesterolemia), gallbladder disease, heart disease, and certain types of cancer, alongside heart failure and respiratory failure.  

They are also likely to become physically ill due to lack of proper nutrition (Yes, you read that right!).

Weight and BMI

If you insist on using BMI as diagnostic criteria or as a tool for defining recovery, you should be aware of its shortcomings.  The most important thing to note is that a BMI of 18.5 is NOT a recovered weight or an IBW for about 95% of the population .  Ergo, 90% of IBW calculated as a BMI of 16.55 as a definition of recovery or as a point to end treatment is wrong.

If all eating disorder patients were the slim, marathon runner genotype, someone would have noticed by now.  The likelihood is that your patient should have a BMI of somewhere between 21 and 25.  Recovery is about optimal function

Eating disorders are deadly and require urgent treatment.

"Get them to eat a sandwich" or "You are not thin enough" or "You have to want to get better" or "She'll probably grow out of it" are not acceptable responses on a patient or a parent presenting with concerns about an eating disorder.  

Eating disorders kill.  Mortality rates for eating disorders vary widely between studies, with sources listing anorexia nervosa deaths from .3% to 10%. One fairly new study compared the records of individuals who had been treated at specialized eating disorders clinics with the National Death Index. Their findings for crude mortality rates were: 4% for anorexia, 3.9% for bulimia, and 5.2% for EDNOS (Crow, 2009). (With thanks to

Eating Disorders are NOT "caused" by any of the following: a cry for attention, the result of abuse, wanting to look like the thin models in the magazines, a control issue or not wanting to grow up.

Get with the programme, people.  It  is 2012 and Hilde Bruche (and her clinical observations) should be left firmly in the last century.  No one knows what "causes" an eating disorder and any, or indeed all, of the above may have contributed to a patient's eating disorder.  That is not the point.

People with eating disorders are severely physically and psychologically ill.  They do not need to "find their bottom" or "work out what caused it".  They need urgent and specialised medical and psychological help NOW.  

Prejudging what may have precipitated their descent into an eating disorder and labeling eating disorder patients or their caregivers does not help them recover.  Trying to work out what "caused" their eating disorder and disregarding their physiological needs puts them at a greater risk of long term physical impairment and, in 15% of them, at risk of death.

Patients don't choose eating disorder: Parents don't cause eating disorders

Often parents are the best resource to help a patient.  I am not saying there aren't any terrible parents out there.  There are.  However, the majority of parents are good people with their children's best interests at heart.  They are motivated, don't have a "clock-off" time, don't require paid holidays, or paid anything, are patient and loving.  When they present in your surgery the first time, they may be bewildered, angry, upset, frightened and anxious.  This is a normal reaction when your child is ill.  Ask any oncologist.




  2. Anonymous18 July, 2012

    Great post, and I pretty much agree with all of it. The only point I would add is that the stimulus for the onset of the disordered eating that develops into a clinical eating disorder (ED) can be relevant, especially if the stimulus involves serious trauma - as in the case of sexual abuse.

    Most people with an ED have NOT been sexually abused, but some have, and sexual abuse IS considered a 'risk factor' for EDs even though it is not the actual cause of the ED. That is, one might say that there is a trigger for the onset of disordered eating that can lead to metabolic changes which disrupt the functioning of the brain in people with an inherent vulnerability. If we think of the recent legal case involving 'E' that was widely reported in the media, sexual abuse made re-feeding MUCH harder, because 'forced' re-feeding was a re-enactment of past trauma.

    Thus, understanding the nature of the stimulus for the onset of disordered eating can be very relevant in some (but probably not all) cases of EDs.

    Another point is that there is research evidence to suggest that a significant proportion of people with EDs have a neurodevelopmental condition (e.g. autistic spectrum). In this case, prior knowledge of the presence of autism may be important (e.g. via a developmental history) because it may be that such individuals need different types of treatment and different approaches to re-feeding to take into account very high levels of anxiety, sensory sensitivities etc.

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  4. ELT

    Points both taken. This particular blog is aimed at your common or garden, overworked, GP who has not seen a case of an eating disorder and has probably missed the three hour lecture about it whilst at medical school.

    Your points are going to be co-opted into my blog of "what eating disorder professionals should know", if that's OK?


  5. Anonymous18 July, 2012

    That's fine Charlotte :) xx

  6. Great posting Charlotte!

  7. ELT, I applaud your caution that we need to evaluate all factors a person with mental illness is dealing with - developmental, environmental, and experiential. But I must beg that we tread carefully with that line of thinking. It is true for ALL mental health issues and for medical ones as well and unless we are going to require that any discussion of depression, heart disease, and MS also have a caution about the possibility of abuse or trauma then we risk continuing a very harmful automatic association between EDs and abuse - a history that has caused no end of misguided treatment and been used as a way to separate parents from their kids at the most vulnerable time.

    Anyone who has experienced the trespass of abuse needs and deserves help whether they present with an eating disorder or not. Abuse is a risk factor for most mental disorders, but notably not for anorexia and not strongly for other eating disorders compared to other mental illness.

    Abuse is terribly, tragically frequent in the population. This is an issue for all of society, an urgent one.

  8. Anonymous20 July, 2012

    There is a huge difference between discussing mental health issues and purely physical health issues in terms of whether or not they were caused by 'abuse'. Abuse doesn't change the structure of someone's heart, but it CAN impact their behavioral patterns related to nutrition, exercise, etc, that can lead to increased risk for heart disease. And, unless those behavioral issues (related to trauma) are addressed, the damage to the heart will continue. Ignoring them will not fix the problem.

  9. Anonymous21 July, 2012

    Thank you Anonymous; I agree. So, Laura, are you suggesting that if a person with an ED has suffered abuse before the onset of the ED and has PTSD, that the PTSD is ignored?

    Abuse, which can include bullying by peers, can have a profound impact on a a person's sense of identity, self esteem and ability to form relationships. Can this feed into an ED? Possibly - and probably. Abuse may not feed into the mechanism of the ED itself, because EDs are self-perpetuating, as are alcohol and drug abuse; but it can sure be a potent trigger. Ask anyone who has co-morbid ED and PTSD.

    And no, it doesn't need to lead to separation from parents or misguided treatment. Good professionals who deal with co-morbid ED and PTSD don't assume that every patient with an ED has been abused. They don't ask that question outright and automatically separate patients from family. They don't leave an anorexic person to continue to starve while they try to work out if their patient has been abused. Abuse can occur from outside of the family without the family knowing about it.

    You know I love FEAST, but the idea that all EDs are merely genetically-underpinned 'brain disorders' is not helpful. There is no reliable evidence to support such an over-simplistic hypothesis. Our brains develop in accordance to every piece of sensory information they receive. It is true that there are inter-individual variations in sensory information processing and that some people's brains are more resilient to stress than others, but life experiences cannot just be ignored - in any mental illness.

  10. As a parent,I think we should not be afraid to acknowledge that all sorts of things can contribute to the onset of an eating disorder and I remember reading that patients with anorexia may find some situations extremely stressful that other family members let wash over them.

    I believe that eating disorder patients may react to stress in a different way and things that I do NOT find traumatic, others with extreme sensitivity may find extremely and damagingly traumatic. It is a matter of perception really.

    Whilst I stand by all the FEAST principles, I do think that completely ignoring the sensitivities of an eating disorder patient is dangerous. An ed patient's reaction to a situation can be very different. I suspect they are what my mother would call "sensitive little souls". I also suspect that ed patients who have been subjected to the kind of trauma ELT is talking about may need a modified treatment protocol to avoid PTSD.

    Parents don't cause eating disorders.

    Just sayin....

  11. Anonymous21 July, 2012

    I agree that parents don't cause eating disorders. I also agree that people who are vulnerable to EDs (especially AN), are very sensitive people with low resilience to stress.

    The point I was making above, was NOT that 'abuse causes EDs'. I said that there is sufficient evidence to suggest that EDs are self-perpetuating. But co-morbidities such as PTSD can feed into the thinking of a person with an ED and either complicate recovery, or require that the person's recovery is managed differently to that of people who are not traumatised.

    There are many pathways into an ED and the pathway into the ED can affect the thinking of the person with an ED. Would it be fair, just and helpful to an ED patient for a professional to tell them "your fear of being raped again if you gain weight is just a figment of your imagination and a symptom of your genetically underpinned brain disorder, so I will ignore it..."?

  12. I fear Laura is coming from a background (as am I) where we were made to feel responsible for our child's eating disorder. The implication were not only in the questions asked, but also in the attitude so naturally I am very defensive about the "abuse" accusation. I am not alone in receiving this kind of disempowering (and frankly libellous) insinuation and questioning.

    I think that PTSD and reaction to stress may play a much larger part in the onset of an eating disorder BECAUSE ed patients are sensitive and less resilient to stress (thank you for the translation, ELT). Maybe their perceptions and reactions to what I refer to as "every day knocks and bumps" trigger some kind of stress reaction that other, less sensitive blundering elephants (like me!) don't get. How do we know?

    What made me slightly wince, ELT, about the whole abuse thing is having been on the end of them looking at me (refrigerator mother?) and darling h (abusive father?) as if we were some kind of psychopathic monsters. Hence, I am nervous to bring the subject of abuse into a conversation about eating disorders.

    However, I do believe that we can't ignore what is out there. It is difficult to protect parents who are good parents, going through an incredibly stressful time trying to save their children's lives AND to talk about the emotive stuff - abuse, PTSD, trauma - that has been held over parents' heads as "your parents' fault" for so long.

    Darn Hilde!


  13. Anonymous21 July, 2012

    I totally understand why you feel this way, Charlotte... I can fully understand why you, Laura and so many other parents shy away from the idea of EDs and abuse being linked in any way; attempt to find as much evidence as possible that refutes such a link; or get very upset at the idea. As you know, I have a very good relationship with my mother and there is absolutely NO WAY that she or my (late) father caused my AN. Yet, for many years my mother lived with terrible and totally unnecessary guilt, because although she was never 'blamed' by professionals for causing my AN, she was sure she must have done so in some way. I never blamed her for my AN and would get very upset in my teens when she blamed herself.

    I am a very sensitive, anxious, obsessive and perfectionistic person. I am pretty sure that these characteristics contributed to the development of my AN. But I did experience bullying and abuse from outside of the family (unbeknown to my parents), which I know contributed to the thinking that underpinned my AN. I didn't fear getting fat and I didn't feel pressured by our culture to be thin. I was already thin... But I did initially associate weight gain with a fear of being raped again. I also felt I was defective, because I was somewhat nerdy. After a while, the AN just became a means of controlling any sort of stress (or trying to control it..) - and a 'habit'. To recover to the level I have done, I HAVE had to tackle abuse issues in therapy - and it has been very helpful.

    The problem arise when professionals assume that all EDs are caused by abuse/neglect/over-controlling parents etc., or that all ED patients have PTSD. Good professionals start with a blank canvas in terms of triggers and don't make any assumptions. I told my psychiatrist that I was abused. He never asked me.

  14. Abuse and trauma of any sort MUST be considered and addressed, of course! When I ask that we separate out the threads here I do not mean to dismiss any of them - only to individualize them. All events and predispositions and interventions have an effect on an individual's mental health and mental illness. I do not know where the idea comes from that I am dismissing trauma or PTSD or abuse in any way: in fact I am giving it MORE emphasis by saying it must be considered and addressed regardless of the presence of an eating disorder.