Friday, January 30, 2015

Study group discussion: Eating disorders

Binge eating disorder is when the person stuffs himself in one day and then doesn't eat for a couple of days. In bulimia, patient eats normally / in excess but then voluntarily vomits out the food to avoid gaining from it.

Binging and then not eating  for a couple of days sounds like bulimia nervosa more than binge eating disorder.

People with BED don't compensate for their binges.  People with bulimia do (by restricting, exercise, purging etc).

Restricting is reducing caloric intake.   Purging can be making themselves throw up or by using laxatives.

Anorexics can also restrict and purge. But anorexics don't binge, definitionally.

So bulimics can be over weight, right? Because they binge? And anorexics are typically under weight? I always get the two mixed up!

Bulimics can be overweight or underweight, depending on how successful their compensatory strategies are after they binge (if they manage to throw up most of the food, and also exercise enough to compensate for the calories their body did manage to absorb, they can actually lose weight extremely quickly, like anorexics).

Anorexics are always underweight, definitionally.  If someone has symptoms of anorexia but they aren't underweight (or if they're female and they still have their period), then they'll probably be diagnosed with ED-NOS instead (specifically 'atypical anorexia').


ED-NOS is eating disorder not otherwise specified.

If you recall, anorexia as a symptom and not a disorder just means loss of appetite (I really don't like that it's the same word).  So anorexia nervosa is a disorder largely characterised by not eating (although it's more complex than that, and a lot of anorexics do binge, just not frequently enough to be diagnosed with bulimia nervosa).

A person might also be diagnosed with ED-NOS if they have symptoms of bulimia, but don't binge often enough to be diagnosed with bulimia nervosa.

Up to 60% of people in eating disorder programs have ED-NOS.

It's also sometimes called OSFED (especially if you're not American).  OSFED is 'other specified feeding or eating disorder'.

I didn't know this about this. I thought Anorexia and Bulimia were the only ones!

So does the management of atypical Anorexia differ?

In the new DSM, the amenorrhea criteria of anorexia will be removed. 
So you still have a significantly lower weight than you should with anorexia, but you don't necessarily need to stop having your period anymore to meet the diagnosis.
Because many women even severly underweight can still have their period.
Also "binge eating disorder" is added, which is eating too much but without compensating behaviors.

But previously you had to miss your period 3 months in a row to have anorexia. They removed this criterium

Oh that's why I heard the no period criteria for the first time!

Yep it's new in DSM-V.

And as for the different treatment.. Since you are underweight in anorexia and not usually in ED-NOS, you will find more people with anorexia being treated by refeeding/feeding tube.

I didn't know that, but that's awesome.  It would be better if they removed the criteria for low weight, too, though. I know a lot of people in the pro-anorexia communities tended to want to wait until they met the weight and amennorhea criteria before getting help so that they could be diagnosed with anorexia nervosa instead of EDNOS.

Yep. It's an "honor" to have anorexia, "shame" to have EDNOS because you're not good enough at having an eating disorder and worse when you have bulimia.

It's strange they make a ranking system for eating disorders, while many people will fluctuate between all three disorders in their lifetime

Which is incredibly unhealthy, because:
1. EDNOS can be as physically damaging to your body as anorexia nervosa (bulimia nervosa is less likely to be physically damaging, although Boerhaave's syndrome, enamel erosion etc mostly only happen for bulimia).
2. Eating disorders, like anything else, are far more treatable if caught early.  Discouraging people from seeking help because the diagnosis they'll get is a less desirable one isn't helpful.

That's sad. The criteria shouldn't get in the way of someone who wants help.

I think the ranking system makes sense, though.  A really high percentage of people in the pro-anorexia community are perfectionists.  If the goal is to be skinny, having an eating disorder where the diagnostic criteria include being extremely skinny would be seen as relative success.  I don't think the ranking system is healthy in any way, but it makes sense.

As for bulimia being the worst... there's a pro-bulimia community, too... there isn't a pro-EDNOS community (although they tend to be absorbed by the pro-anorexia one).  So I don't think it's necessarily accurate to put bulimia at the bottom of the hierarchy (although I do realise that a lot of bulimics wish they were anorexic instead because they think they'd lose weight faster that way).

Hmm. So what do you guys think would be a sensitive way to approach eating disorders, in terms of clinical encounters or diagnosis? How might we be more body positive in the clinical setting?

Well it's hard to approach people with eating disorders properly... Because if they are still in denial (much like in addiction), they will see a comment about looking sick as a compliment

Someone asked whether the management of atypical anorexia is different.  In general, all restrictive eating disorders can be seen as fairly equal, and the recovery process is largely similar for anorexia nervosa and atypical anorexia.  The only significant difference I know of is that people with anorexia nervosa are more likely to be put in inpatient, and achieving a healthy weight tends to be more of a focus for anorexia nervosa than for EDNOS.

And yes, being told that they look sick would almost definitely be taken as a compliment.

I see. It's like they are different colors of the same spectrum.

I think what you can do is just ask the patient if they are okay, mentally. If they want to talk about anything, because you are worried.

I had a colleague this past week and she ate next to nothing, so I asked her. And told her if she needs to talk, she can e-mail or call me

Pretty much... I strongly disagree with the way they separate atypical anorexia from anorexia nervosa based on weight.  The psychological symptoms are the same, the mental distress tends to be the same, the treatment is the same, the potential physical harm that the eating disorders cause are the same.

Just never minimize the problem if your patient has an eating disorder, because they will try very hard to prove you wrong

A friend of mine has had people say to her that her eating disorder wasn't "that bad" because she wasn't severely underweight, which stimulated her to not eat. She ended up in the hospital. It's a sensitive subject, so try to get an expert to talk to them instead of potentially saying the wrong things.

I figured it was something like that. But expert aside, seems like it's still important to leave them to open the conversation, similar to any other mental illness and let them talk it out than seek immediate referral.

Definitely :) if you are willing to help and listen, just tell them that you don't know much about it/don't have experience treating people with eating disorders, but you would like to try and help.

As far as being sensitive goes:
1. If a blood test and/or an ECG is part of the diagnostic process (I know it's a requirement for the eating disorder treatment program here, I don't know if it is elsewhere), assuring someone (especially if they aren't thin enough to be diagnosed with anorexia nervosa) that even if the blood test results look 'normal', it doesn't mean that they haven't done damage to their body, and it doesn't mean that they aren't sick enough to deserve help (this is especially true for people who are voluntarily seeking help for an eating disorder).
2. Not telling people to just eat... I don't know why on earth people, including medical professionals, insist on doing this.  It's awful.  Don't.  If it was that simple they wouldn't need medical treatment.
3. Acknowledging that the eating disorder serves as a useful and valuable coping mechanism.  Even though eating disorders are their own special kind of hell to have, the feeling of control they give to people who suffer from them can still feel good and make it hard to recover.  It's possible to be sensitive and acknowledge the things that make it hard to *want* to recover, while still pointing out that on the whole, it's harmful, and recovery would make the patient's life better.
4. If someone has atypical anorexia, don't constantly remind them of it.  They probably think about it a lot.  Saying "eating disorder" validates the severity of what they're going through, and emphasises that all eating disorders are serious and should be treated as equally serious.
5. Unless their life is in immediate danger, don't try to force recovery-oriented behaviours on them.  Let them recover on their own time: it'll make it so that the recovery process is less scary/unpleasant, and will also make it so that their recovery lasts longer.  Eating because you've been forced to isn't the same as eating because you want to recover.  Encourage them to choose recovery on their own.
6. Following on from that... don't just focus on the physical symptoms.  Yes, it's important that people figure out how to eat properly, because not eating properly can result in very serious physical consequences, but it's also very important to acknowledge the mental symptoms, because those can cause very serious effects on the person's quality of life, too.  A friend of mine saw a psychiatrist for anorexia nervosa, and the psychiatrist kept focusing on her weight, and as she reached her healthy weight, the psychiatrist acted as though that meant she was nearly recovered.  Never forget that eating disorders are mental illnesses, and just because someone's at their healthy weight doesn't mean they're recovered, or that they don't still need help.

I have mixed feelings about handling co-morbidities, because I don't know a lot about them.  I know that there are segments of the medical profession who believe that if someone presents with a comorbid eating disorder and anxiety/depression, that they'll try to treat the eating disorder first before doing anything about the anxiety/depression.  Which to some extent makes sense, because not eating can do weird things to mood, but I personally don't really like that approach (especially in cases where the anxiety/depression clearly was present before the onset of the eating disorder).  I do know, however, that if a medical professional takes the view that the eating disorder should be addressed first, it can definitely come across as them dismissing the mood and anxiety disorders as being just a by-product of the eating disorder, which can be incredibly invalidating.

I feel anxiety & depression should be addressed along with the more obvious eating disorder. But I don't know if it's feasible in clinical practice.

You can ask the patient to talk about it, sure. But if that doesn't work pharmacological treatment takes weeks. And you never know if the eating disorder caused the depression or vice versa, the depression caused the eating disorder. I really don't get how a psychiatrist would actually approach and manage such a patient.

Comorbidities are messy.  Eating disorders tend to make anxiety/depression worse, but anxiety/depression (especially anxiety) can make eating disorders worse, too.  In light of that, I feel as though treating them both at the same time makes sense because reducing the symptoms of the depression/anxiety might make the eating disorder better, even if the eating disorder is the cause of the depression/anxiety.

I know there are psychiatrists who will prescribe antidepressants and/or anxiolytics for people who have eating disorders.  But also doctors who insist on treating the eating disorder by itself first. I don't think there's a general consensus on what's the best way to handle that.

As for feasibility in clinical practice, I personally think it makes more sense to address depression/anxiety at the same time as the eating disorder, especially where it isn't certain whether any given symptom is caused by an eating disorder or anxiety (if someone's afraid to eat in public, is it general social anxiety or the eating disorder?... there's no real way to tell... but it's not important, because either way the symptom needs to be addressed)


Would it help treating an anorexic patient indirectly?  Say, you need to gain a little weight back even though you might not like it because.. Idk.. You have amenorrhea? And that's bad etc etc
Or is that even allowed?

Anorexic patient: I doubt it would help.  At a fairly early point in eating disorders, the desire to be thin begins to take on an irrational level of importance.  It's not uncommon for anorexic patients to express the idea that they don't care if they die, so long as they can die skinny.  Although in the early stages of illness, a lot of anorexics desire to be skinny so that they can be beautiful, or popular etc, at some point it often takes on an importance of its own, and they'll be willing to risk everything (health, beauty, popularity etc.) to be skinny.  When it gets to that point, curing amennorrhea isn't really going to be enough of an incentive to overcome the obsessive desire to be thin.

Even if they gain back the weight, you might end up in a yo-yo weight situation where any underlying disorders keep cropping up, particularly in times of stress. Eating disorders tend to be chronic and long-lasting.

Telling someone that something they do is "bad" also probably isn't really compelling, even though lots of people try that tactic :p

That is also true.  And as I said before, although gaining back the weight can be important, it's even more important to deal with the underlying mental illness.

So, it would still be difficult to show them that hey! You are back to normal weight and still looking good? As in their perception just won't change?

Once people get close to being at a normal weight, they often feel that they look incredibly fat (and in comparison to their emaciated bodies they had while severely underweight, they probably do).

I guess it makes if I think according to their thoughts.

There was an experiment where people were starved and they started engaging in disordered eating behaviour, but once they reached their healthy weight again the disordered behaviour went away.  The problem is, that only seems to be true for people who developed disordered eating behaviour after losing weight.  For people who lost a lot of weight as a result of disordered eating, regaining the weight doesn't seem to usually fix the problem.

Which is why I so strongly disagree with any treatment approach that focuses on regaining a healthy weight, and using weight as a marker for how healthy a person is.  Because if someone recovers enough to be at a healthy weight but doesn't recover fully mentally, chances are they're going to revert back to old behaviours again.  Relapse and recovery cycle and all that.

Full recovery is generally possible for restrictive eating disorders, in that a lot of people never do go back.  But that only happens if the underlying eating disorder is adequately dealt with, and not when the only recovery that has happened is weight restoration.

It falls to dealing with the cause versus dealing with the symptoms.


So if we don't talk about weight, how do we bring them back to a normal mental state?

Well the mental state is the problem the weight is just a visible symptom of that.

Eating disorders are often very helpful to people who have them, even if they cause a lot of suffering.  They're a way of being able to exert control in a chaotic world.  It's why eating disorders are so common among young people with controlling parents.  Eating can often be the only thing that people can control if they live in highly restrictive environments.

So changing how you think about the illness is an important first step?

To that end, making sure that people with eating disorders find things in their life that they can have control over in healthy ways can be really valuable.

Many associate these with vanity which undermines the sickness.

It has a stigma sort of like depression, where it used to be considered that the person was just sad or moody but now we know it is an imbalance of neurotransmitters that is the cause.

It's important to take. the patient seriously and treat it as a real illness so that the patient can feel that they can be cured and recover, like most illnesses.

Definitely acknowledging that it's a real medical illness and not just something someone is doing to themselves is important.  Validating someone's experiences is one of the most important things about dealing with patients, and especially important in cases of mental illness.

Validating that's the word.
Couldn't for the life of me recall it.

One more question, mentioned that one way would be to make sure they have control over other things in life in healthy ways. What exactly do we mean- lifestyle?

If they're a child, ask their parents to give them more freedom to make choices in their life.

If they're an adult, talking to them about the areas in their life where they feel they have no control, and helping them see that they do actually have quite a lot of control can be helpful.

Although that can be tricky, a lot of people with eating disorders have been victims of trauma, and that's very much a situation where they did not have control.

I see. This was incredibly insightful. Thank you guys!

You should also try to focus on giving them better coping mechanisms and expressing their feelings. A big part of eating disorders is also about not feeling, not dealing with emotions. They need to know it is okay to cry, that they can deal with whatever caused the disorder in a healthy way. And especially let them know that yes, even though this coping mechanism was helpful in the past (for example in cases of abuse), it is no longer necessary to survive.

It makes me really happy that people in this group were so willing to listen when we were talking about what to do with patients who have eating disorders.  And your desire to make a difference when you're in clinical practice.  I like how everyone in this group seems to genuinely care about being a good doctor and to care about patient welfare.  I think that's really important, and it makes me hopeful about the future generation of doctors to see how much you care.

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