• What is an eating disorder?

    Eating disorders develop due to a variety of physical and emotional issues which need to be addressed for effective prevention and treatment.There are several types of eating disorders:

    Anorexia nervosa (AN) involves severe restriction with resulting malnutrition and a refusal to maintain a weight within a healthy range.

    Bulimia nervosa (BN) is characterized by a cycle of binge eating followed by a compensatory behaviors such as self-induced vomiting, use of laxatives, diuretics or excessive exercise to purge calories consumed.

    Eating Disorder Not Otherwise Specified (EDNOS) involves a combination of the above behaviors but does not meet the full criteria for diagnosis of either AN or BN. The physiological and psychological consequences of this disorder are still severe.

    Binge Eating Disorder (BED) is a diagnosis under EDNOS referring to binge eating without the compensatory behaviors seen with BN.

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  • Is an eating disorder life threatening?

    Yes! Depending on the circumstances, individuals with eating disorders may be at great risk of a number of life-threatening medical conditions. The eating disorder behaviors and resulting state of starvation (often in spite of appearance of normal or overweight status) affect every body system. Often these effects are undetected due to the body's attempt to compensate for the starvation and an uneducated health professional may ignore signs of an eating disorder in the face of "normal labs." However, physical symptoms such as fatigue, difficutly sleeping or concentrating, hair loss or dry skin may be explained by the malnutrition seen with an eating disorder. More serious underlying conditions may also exist including low heart rate and blood pressure, decreased hormone production and decreased organ function. These conditions call for emergency assessment and response. Although medical professionals can identify an emergency situation in progress, it is hard to detect an impending medical crisis. Given the high rates of suicide in patients with eating disorders, a careful assessment of suicide risk should be undertaken as well.

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  • When is emergency treatment needed?

    Emergency treatment should be sought if any of the following conditions arise:

    •     Rapid weight loss, such as more than 15 lbs within 4 weeks
    •     Seizures
    •     Organic brain syndrome
    •     Slow heart rate (bradycardia, or fewer than 40 beats/minute)
    •     Other irregular heartbeats
    •     Frequent chest pain on exercise
    •     Volume depletion
    •     Painful muscle spasms (tetany)
    •     Quickly becoming tired while exercising
    •     Low urine output (less than 400 cc/day)
    •     Faintness
    •     Severe electrolyte imbalance

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  • What can I do to help someone with an eating disorder?

    The support of a spouse, parent, sibling, or friend is one of the most valuable tools a person with an eating disorder can have. If someone close to you has an eating disorder, you can face it together, but remember that they are the one with the problem. Loved ones can research treatment options, read appropriate books, attend lectures, talk to experts, and lend a supportive ear, but only the patient can do the work.

    Keep in mind that an eating disorder is a way to feel in control of one's life. Sometimes, what is intended to be helpful and considerate can be interpreted as controlling by the person with the disorder. Communicate that you are available to help, but that is not your job to patrol their behavior. You are there to support and encourage them in their sturggle to get well, but only if that is what they want.

    An eating disorder is a protective device used to handle pain. If it was easy to give up, the person would have done so already. Someone who uses food as a coping mechanism needs understanding and compassion. The reality of the disorder may shock or disgust you, but separate the individual from the behaviors. Your loved one deserves love and appreciation for who he is apart from the disorder. If a loved-one became disabled or ill, you would still be there for them - keep in mind an eating disorder is disabling and life-threatening.

    At the same time, do not be manipulated or lied to for the sake of the eating disorder behaviors. Do not "enable" the disorder by looking the other way or pretending that the problem is not serious. If you stock the refrigerator with food only to have it flushed down the toilet, be honest and assertive about your rights and needs. Patients should not be allowed to abuse your trust or pocketbook; having an eating disorder is not justification for treating loved ones poorly. Also, don't turn meals into battles - food is not the issue.

    Parents of patients with eating disorders especially need to be aware of their limitations in helping their children. Often, the relationship is too close for objective evaluation. Let your child open up to you with feelings, and if he does not make progress with your support within a short time, encourage professional therapy. It may also be appropriate for parents to seek out professional advice or a support group for help with their own feelings of frustration and helplessness.

    Parents usually play a part in the development of their child's behavior, and in many instances, may have to face issues and make adjustments of their own. This is not to say that they are the cause of the eating disorder, but rather that they may have contributed to it in some way and need to acknowledge that. Parents may need to reevaluate their values, ways of communicating, family rules about food, ways of handling feelings, parenting roles, and the family's decision-making process. Guilt, anger, frustration, denial, and cynicism are all likely sentiments.

    As hard as this all sounds, family therapy has proved to be one of the most successful methods of overcoming eating disorders. With better communications, increased self-knowledge and mutual acceptance of what has happened in the past, parents and children can focus on the important task of recovery in the present.

    Reprinted from Bulimia: A Guide to Recovery

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  • Why do patients resist treatment?

    According to Drs. Elliott M. Goldner and C. Laird Birmingham, and Victoria Smye, MHScB, of the University of British Columbia, people struggling with eating disorders may have many reasons for refusing treatment. Some don't think they have an eating disorder at all and feel that their family or friends are exaggerating the problem or are mistaken about the symptoms.

    Others may be well aware that they are struggling but are ashamed of their symptoms and afraid of being discovered. Many fear the potential effects of treatment, such as weight gain or interference with their drive to exercise, restrict food intake, purge, or lose weight.

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  • What happens if a patient is resistant to treatment?

    Treatment is typically begun with some hesitation on the patient's part however part of the treatment plan will be to work through that resistance. Improving nourishment and working on motivation with a counselor expedite this process.

    In some cases, physicians must consider imposing treatment even when the patient actively resists. Individuals who may be at increased risk include: (1) young patients who have recently developed symptoms; (2) patients who are in immediate danger because of medical consequences of the illness or the risk of suicide; and (3) those with rapidly increasing symptoms.

    When physicians decide to "order" treatment, they fully believe that treatment will be beneficial. Many patients in these situations are likely to benefit even if they don't recognize or support the plan.

    When treatment is imposed against a person's wishes, the consequences may be great. Thus, physicians carefully weigh the potential benefits versus any risks before beginning. Sometimes, physical and chemical restraints are used, along with tube feeding and restriction of activity. In such settings, patients are often profoundly distressed and as a result avoid further treatment. However, in other cases, once adequate nourishment is achieved, allowing the patient to think more clearly, treatment can be continued and completed.

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  • What about an individual's legal right to refuse treatment?

    All jurisdictions have laws upholding the rights of individuals; thus, an individual's right to refuse treatment may be supported by the court. Minors and other individuals who are deemed incompetent (a legal term meaning that a person is mentally incapable of making his own decisions) may be temporarily denied the right to refuse treatment.

    While they are competent in all other areas, individuals with eating disorders are often considered incompetent in certain specific areas of their lives, including decisions about their ability to gain weight or their current health and need for treatment. However, patients have a legal right to dispute this, and health-care providers must then turn to the legal system to support the need for imposed treatment. Other-health care providers will be asked to give a second opinion, and to estimate the risks involved if the patient were to have no treatment.

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  • What advice can be offered?

    Because of the many consequences when a patient doesn't want to be treated, and the effects on families as well, health-care professionals often use a careful process in order to convince the patient to be treated before seeking legal means to accomplish this.

    Advice for Loved Ones

    1.  First, try to engage the patient in a voluntary partnership.

    2.  Explore the reasons that the patient is resisting treatment. It may be a fear of the unknown or he or she may be frightened by psychiatric or medical interventions in general. Other patients are severely depressed or have cognitive impairment. Most often, refusal to be treated is caused primarily by a cognitive disturbance or such things as a fear of gaining weight.

    3.  Before starting treatment, some facilities use a preliminary intervention. During these sessions, information is provided to the patients and family members, goals of treatment are identified, staff members are introduced, and individual concerns are addressed. It is also explained to the patient why a certain treatment is recommended, and what that treatment is. This helps enhance motivation for change.

    4. Involving the family in a realistic treatment plan usually improves the effects of therapy. This approach lessens power struggles and adapts treatment to the unique qualities and characteristics of each family

    5.  Negotiations may be necessary. In order to promote the health and safety of the patient, professionals may need to make changes to the proposed treatment plan. Individuals with eating disorders are much more likely to respond to a professional who is approachable, flexible, and comfortable dealing with conflict.

    6.  All treatment plans should minimize the use of intrusive interventions, such as involuntary commitment to an inpatient unit, tube feeding or programs of behavior modification. Whenever possible, outpatient programs, day programs, and residential treatment should be used instead of inpatient treatment.

    7.  A realistic appraisal of the probable outcome of treatment versus no treatment will help guide the clinician to a rational plan. Imposing treatment should be considered only when the possible benefits outweigh the risks of not intervening.

    8.  Power struggles between the patient and the health-care team usually worsen symptoms and break down the therapeutic partnership. Patients who feel frightened or trapped may battle staff, have angry outbursts, or withdraw. It is important for health care professionals to remain respectful and avoid threats or destructive criticism. Treatment should support self-esteem.

    9.  Due to potential risks, it is generally agreed that legal means of imposing treatment should be reserved for cases in which doing nothing would lead to a serious and immediate danger.

    10.  Patients who have struggled with eating disorders for a long time often need a different approach than those who have been ill for a shorter time. Chronic illness may indicate a particularly resistant eating disorder and it may be inappropriate to approach treatment of the chronic anorexic patient with a more aggressive plan for intervention.

    11. Refusal or resistance to treatment can be viewed as an evolutionary process. Indeed, individuals who refuse treatment at first may later accept it. Usually the gradually increasing recognition of the negative impact of an eating disorder on a person's life is accompanied by a wish to recover. After refeeding has begun, patients may need less treatment due to improvements in emotional and cognitive processes.

    Reprinted from Eating Disorders Today
    Vol 1, No. 4 ©2002

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