Sick Enough

A Guide to the Medical Complications of Eating Disorders

Jennifer L. Gaudiani

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781351184717
• Edition: 1
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Patients with eating disorders frequently feel that they aren't "sick enough" to merit treatment, despite medical problems that are both measurable and unmeasurable. They may struggle to accept rest, nutrition, and a team to help them move towards recovery. Sick Enough offers patients, their families, and clinicians a comprehensive, accessible review of the medical issues that arise from eating disorders by bringing relatable case presentations and a scientifically sound, engaging style to the topic. Using metaphor and patient-centered language, Dr. Gaudiani aims to improve medical diagnosis and treatment, motivate recovery, and validate the lived experiences of individuals of all body shapes and sizes, while firmly rejecting dieting culture.

Part I

Not Enough Calories

Let’s start by talking about starvation. When I say starvation, I mean any situation in which not enough calories are consumed, over some period of time, to fulfil the body’s needs. Starvation can occur in people of any body shape and size. It doesn’t just happen in people with lower body weight, although society and the medical profession may not understand this fact. All too often, weight stigma causes patients in larger bodies to be praised for engaging in the same eating disordered behaviors that in an underweight person would cause great alarm. Low energy intake can occur during an eating disorder or disordered eating, but it can also happen when someone goes on a diet or participates in a fast or a “cleanse.”

The Diagnostic and Statistical Manual-5, also called the DSM-5, published by the American Psychiatric Association and updated every decade or so, contains the official diagnostic criteria for mental illnesses.¹ All eating disorders are characterized by aspects of inadequate caloric intake with attendant risks of medical complications. Practically no one with an eating disorder stops eating and drinking altogether; that is a popular misconception. These are complicated illnesses that emerge from a combination of genetic, inherited temperamental traits and physiological, environmental, and sociological factors. I’ll start by reviewing the definitions of the eating disorders most specifically tied to insufficient energy availability.

Anorexia nervosa is diagnosed when an individual persistently restricts caloric intake, leading either to significantly low body weight (related to what is minimally expected for age, sex, and health) or to arrested growth in children or adolescents. In addition, patients experience an intense fear of gaining weight or becoming fat, develop distortions in the way they perceive their bodies, and deny the severity of their behaviors and risks of low weight. Patients’ sense of self-worth becomes unduly influenced by their body size and shape.

Anorexia nervosa comes in two subtypes: restricting and binge eating/purging. While both subtypes may manifest obsessive and compulsive overexercise, those with restricting anorexia nervosa purely limit calories. By contrast, those with purging anorexia nervosa may or may not engage in binge eating, but eating of any kind is frequently followed by compensatory behaviors such as vomiting, laxative abuse, or diuretic abuse (see Part II for further discussion of these behaviors). In both subtypes, patients by definition are significantly underweight. In general, anorexia nervosa has a prevalence of around 1 percent, with a ratio of females to males of 10 : 1.²

In atypical anorexia nervosa, which falls under the DSM-5 heading of other specified feeding and eating disorders (OSFED), patients engage in all the same behaviors and have equally severe body image distortions and fears as those with anorexia nervosa, but they are not formally underweight. Patients may lose a significant amount of weight and may be underweight relative to their typical body weight. Atypical anorexia nervosa is by far more prevalent than anorexia nervosa, occurring in up to 3 percent of the population in one large study.³ The fact that these individuals receive the designation “atypical,” despite representing by far the greatest number of patients with symptoms of anorexia nervosa, speaks to the ongoing problem of size stigma in medical and mental health communities.

In my clinical experience, many individuals with atypical anorexia nervosa don’t believe they have an eating disorder because they aren’t stereotypically emaciated. This is only reinforced by society and by medical providers who not only miss the eating disorder but praise such patients for their weight loss and presumed “health” when, in fact, the behaviors being used are the opposite of healthy. A recent study found that adolescents with atypical anorexia nervosa presenting to a specialized pediatric eating disorder unit were just as psychologically and medically ill as the patients with typical anorexia nervosa.⁴

In patients with atypical anorexia nervosa, if weight is checked during medical assessment, the calculation for “weight suppression” should be used. Weight suppression refers to the percentage of body weight lost, calculated as the highest recent body weight minus the current body weight, divided by the highest recent body weight. Weight suppression of even 5 percent, in the presence of anorexia nervosa symptoms, has been found to be clinically significant.⁵ Of course, given that some individuals never lose weight, the whole person and their overall medical and psychological state must also be taken into account. Individuals with atypical anorexia nervosa, regardless of body shape and size, are unquestionably sick enough to seek treatment and recovery.

Patients with avoidant restrictive food intake disorder (ARFID), discussed in Chapter 14, also fail to take in enough calories, but without the focus on and distortions of body size and shape. The medical complications of starvation that will be discussed throughout Part I apply to them as well.

In Chapter 1, I will introduce the three main medical issues that emerge from starvation: slowed metabolism, organ dysfunction from insufficient energy intake, and treatment of malnutrition. These provide an organizing framework upon which we can understand most of what happens to the body when it receives inadequate calories. I will go into greater detail on each of these topics in Chapters 2, 3, 4, and 5.

Notes

1American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed.) Arlington, VA: American Psychiatric Publishing; 2013.

2Lindvall Dahlgren C, Wisting L, Rø Ø. Feeding and eating disorders in the DSM-5 era: a systematic review of prevalence rates in non-clinical male and female samples. J Eat Disord. 2017 December 28; 5:56. doi: 10.1186/s40337-017-0186-7.

3Hay P, Mitchison D, Collado AEL, González-Chica DA, Stocks N, Touyz S. Burden and health-related quality of life of eating disorders, including Avoidant/Restrictive Food Intake Disorder (ARFID), in the Australian population. J Eat Disord. 2017 July 3; 5:21. doi: 10.1186/s40337-017-0149-z.

4Sawyer SM, Whitelaw M, Le Grange D, Yeo M, Hughes EK. Physical and psychological morbidity in adolescents with atypical anorexia nervosa. Pediatrics. 2016 April; 137(4). pii: e20154080. doi: 10.1542/peds.2015-4080.

5Forney KJ, Brown TA, Holland-Carter LA, Kennedy GA, Keel PK. Defining “significant weight loss” in atypical anorexia nervosa. Int J Eat Disord. 2017 August; 50(8):952–962. doi: 10.1002/eat.22717.

Chapter 1

30,000-Foot View

What Happens When You Starve Yourself?

Background

In clinic with patients and their families, when I discuss the topic of how starvation affects the body, I start by introducing the concept of the “cave person brain.” The cave person brain refers to the part of our brain that manages the day-to-day functions of our bodies. It takes care of us as a mammal, rather than as a thinking, talking human being. It manages our temperature, digestion, heart rate, blood pressure, reproductive hormones, and to some extent, our animal reactions to the world, among others.

The Cave Person Brain and Metabolism

When our cave person brain senses it is not getting enough to eat, it has no insight that an eating disorder is enforcing food rules, that self-imposed or external bullying is driving a diet, or that everyone at work is doing a “cleanse” this week. It can only interpret, “We must be in a famine. We have to protect our person.” Humans have survived as a species in part due to our exquisite ability to tolerate starvation. Our ancestors frequently faced food shortages. The cave person brain evolved to be highly responsive to this stressor.

When a person consumes too few calories, the cave person brain decreases their metabolic rate so that fewer calories are burned. As I will detail in Chapter 2, it does this by slowing down our heart rate, lowering our blood pressure, slowing our digestion, reducing blood flow to our hands and feet, and decreasing our feeling of energy to get things done, in order to make us hold still and conserve energy. This increases the likelihood that the person will survive until food is again available. In addition, the cave person brain fiercely strives to maintain our body weight.

What is metabolism, though? It’s talked about all the time, and there is a lot of pseudoscience propagated about it. While “metabolism” refers to all biochemical processes that sustain life, I generally use the term “metabolism” to describe what is formally called “basal metabolic rate,” which is the number of calories a body burns each day just by existing. Most of our daily caloric expenditure goes toward maintaining our body temperature at almost exactly 98.6 degrees Fahrenheit. We also burn calories for digestion, organ function, and hormone production. We use up far more calories to maintain a consistent temperature than we do going to the gym.

Exactly how the cave person brain responds to inadequate energy intake is highly variable from person to person, due to genetic factors. That is, if you have four people of similar age and body size who restrict calories similarly and move their bodies at a similar pace, they might have widely varying physiologic responses. One person might develop a slow heart rate but have normal digestion and energy. Another might have a normal heart rate but be plagued by slowed digestion. Yet another might lose lots of weight, while a fourth might lose almost no weight at all.

This variability poses a frustrating challenge for my patients. Many have been invalidated by medical providers and society at large. Despite severe mental illness that drives them to engage in serious eating disorder behaviors, they may “look normal” and thus don’t generate appropriate concern or attention from some providers or others in their lives. Others suffer because, despite eating disorder behaviors, they have such protective genetics that they manifest almost no physical signs of malnutrition. Unfortunately, this further feeds into the eating disorder voice that tells them they must be fine since they look fine, that they need to push harder to lose weight.

Yet others can’t believe how quickly they develop medical problems, even in the early days of an eating disorder or at a higher weight. They see an image online or a peer who looks “sicker” (i.e., usually meaning thinner), while they themselves hit a medical wall at a higher weight. All of these patients suffer from not feeling “sick enough.”

The explanation for this variability probably lies in genetic subtleties that we cannot yet pinpoint. Bodies clearly have different genetic susceptibilities to what I broadly call “environmental exposures.” When I talk with patients about this, I tend to remind them of a more familiar scenario. A 35-year-old man might die from liver failure after ten years of heavy drinking, while a 90-year-old man on his birthday might attribute his long life “to the whisky.” What is the difference between these two heavy drinkers? All one can conclude is that they must have had different genetic sensitivities to environmental exposures.

Similarly, when my patients manifest few medical issues and a stable body weight despite eating disorder behaviors, I first validate that the behaviors themselves are worthy of care and treatment. I identify they must come from “survivor” genetic stock; their cave person brains are remarkably effective at defending their bodies from the effects of starvation. For others who develop medical problems early on in their eating disorder, I note they are genetically “sensitive.” It’s lucky they came to medical attention early before their eating disorder worsened. When examples of these differing clinical presentations arise, I will refer to them as “genetic variability.”

Starvation and Hormones

There is another vital way in which the cave person brain reacts to starvation besides slowed metabolism. This is through radical changes in our hormones. When we starve ourselves, our brilliant cave person brain says, “Ah, I see we’re in famine. This body is stressed out by too much activity and too little energy intake. Clearly it’s not a safe time to produce a child.” Accordingly, in adolescents and adults, the part of the brain called the hypothalamus essentially rolls hormone production back in time and produces preadolescent sex hormone levels, a condition called hypothalamic hypogonadism. As Chapter 3 will detail, this results in low estrogen levels and sometimes menstrual abnormalities for females and low testosterone levels for males. The complicated interplay of high stress hormones and low sex hormones in both sexes can lead to the one irreversible medical complication of prolonged malnutrition, one rarely anticipated by patients: bone density loss.

Starvation and the Brain

The last major way in which the cave person brain changes in response to starvation is to become vigilant and anxious. Remember back to when your pet last experienced a big thunderstorm. For some period of time after feeling threatened physically, your pet likely acted skittish. Maybe the cat got under the bed, eyes huge, tail puffy, claws ready. That is essentially what happens in the malnourished cave person brain too. The animal brain understands, “I’m at risk here. I’m vulnerable. I might not survive a dangerous encounter.” So, it up-radars all of its risk monitors.

In a similar way, the malnourished person is constantly scanning the world for threats. That mental activity makes them much more rigid, resistant to change, and truly fearful much of the time. I have heard my patients say things like, “I’m terrified that it’s almost lunchtime.” I reassure them that much of this heightened animal anxiety is not fundamental to who they are and isn’t even part of their eating disorder or anx...