Anorexia nervosa and Bulimia nervosa are serious medical conditions, requiring
formal diagnosis [by a licensed diagnostician: MD or LNP], and medical intervention under
supervision of qualified medical personnel! Patients presenting with signs and/or symptoms must
be referred for diagnosis! Do not attempt to intervene in suspected cases of Anorexia or Bulimia.
You may advise a friend to seek appropriate treatment, but should NOT tell them that you
suspect an eating disorder [explained below].
The most famous case of Bulimia involved a 26 year old patient. Terri Schiavo
(reported by abcnews4, Charleston, SC, April 1, 2005 [at the beginning of the extensive legal
maneuvering and media circus which the case became, I heard a single report of this on CBS News
radio, WBBM AM 780, Chicago, but abcnews4 was the only reference to it that I was able to find
online in 2007]) was diagnosed as bulimic and later suffered heart arrythmia [irregular heart beat]
leading to cardiac arrest at the age of 26. When she arrived in the ER with full cardiac arrest, the
ER staff immediately attempted to resusitate her, absent a DNR (Do Not Resusitate order) of record.
After she was successfully resusitated, the attending physician began evaluating the extent of brain
damage (finding over 50% loss of brain tissue from the frontal lobes toward the back of the brain)
and diagnosed “permanent vegetative state,” [inability to think, experience emotion, form
or retrieve memory, …] with a prognosis of no hope for recovery. On autopsy, the extent of brain
damage was determined to be more severe than previously thought, with only the brain stem (the
‘primitive brain’ responsible for maintaining life with response limited to instinctive
reaction to stimulus) intact [the entire cerebrum was described to the press as
“liquified”]. The opportunity to educate the susceptible population concerning the severity
of the disorder was lost as the courts (all the way to the U.S. Supreme Court more than once), and
Florida state government, argued over the issue of discontinuing life support.
One of the least famous cases was a former student of mine. When first I met her as a
student in my Intro Biology class [fall semester], she was very thin [similar to illustration 11.2,
pg 11-3] and pale in color, and I suspected she was suffering from Anorexia nervosa. The following
semester I saw her on campus, and she appeared to be somewhat thinner than before. Early during the
next fall semester I saw her walking across campus in front of me; this time she was so skinny that
I could see her ribs under her loose-fitting clothes, and even was able to watch the movement of the
bones in the joints of her knees and elbows. Her skin (where it was exposed at her wrists and hands)
was pure white and non-transparent, like a sheet of paper. I never saw her again after that. I
suspect she died of the disorder during the semester. The point is that these two disorders
(Anorexia & Bulimia) are serious life threatening conditions.
There are several (9) early warning signs that someone might become anorexic, or already be
anorexic [Table 11.1, pg 11-4 gives complete signs and symptoms]. If someone you care about seems to
have lost too much weight [skinny like a high fashion model] and starts exhibiting any of these
behaviors (listed in the order of “typical” appearance for anorexics), they may need
medical attention BUT you can not suggest that you suspect an eating disorder:
# 1. ‘play with’ food rather than eating.
Examples include separating mixed vegetables into separate piles, then stirring them back together;
moving all of a single food to one side of the plate, then to the other side, and back again;
arranging a single food into patterns…
# 2. may exercise compulsively. Here we use the term
“compulsive” to imply that the patient will become agitated and upset if they can not
complete what ever they have a compulsion to do at the moment, and they will resume the activity as
soon as possible [no matter how long it has been since they were interrupted].
<You could suggest that they check with a doctor to make sure that their health is good
enough for the exercise>.
# 3. accepts narrow range of foods. And the number of
foods accepted continually gets narrower, until only a single food (such as garden peas) is accepted.
<You could suggest that they check with a doctor to see if their diet is healthy>
# 4. irritable, hostile, and withdrawn from family and
friends. This is the biggest problem in referring the patient for diagnosis: if you mention
‘eating disorder,’ the patient may react as if you have been “nagging” them about
it for days or weeks, and withdraw from you [so you will not get a second chance to refer them].
<You could suggest that you heard somewhere that moodiness may be a symptom of some
disease>
# 5. school [or work] performance deteriorates.
<You could suggest that they speak to a counselor about “whatever you are worried about
that is affecting your school/work” performance>
# 6. avoid eating with family or friends.
# 7. commonly depression and sleep disturbances.
<You could suggest that there are drugs that treat “mild depression”>
# 8. cessation of menstral periods.
# 9. loss of skin color.
The death rate is 7% within 10 yrs of diagnosis.
Treatment is reported to be effective in 50% of patients, but one third of these “cured”
patients will relapse [resume disordered eating behaviors] within 7 years. These numbers (50%
effective, with 33% relapse) would not be considered acceptable in most diseases (communicable
[bacterial or viral] or life-style related [such as emphysema]).
“Bulimia is estimated to affect … 3% of all women in the U.S. at some point in their
lifetime. … Approximately 10% of identified bulimic patients are men. … The long-term
prognosis for bulimics is slightly better than for anorexics, … However, many bulimics continue
to retain slightly abnormal eating and dieting behaviors even after the recovery period.”
(http://www.medicinenet.com/bulimia/article.htm downloaded 19 May 2009 9:07 am)
The relapse rates I have seen quoted for bulimia are as high as 50%, probably including the slightly
abnormal eating and dieting behaviors mentioned above.
Many patients who have been diagnosed as bulimic have been participants in structured weight loss
programs for self-diagnosis of over-weight conditions. At some point, the patient feels guilty about
their failure to lose enough weight, leading to episodes of starvation dieting followed by the
classic “binge and purge” associated with the disorder. Many of the diagnosed males
were high school wrestlers who had “yo-yo” diets characterized by over-eating during
weight training to bulk up, and starvation dieting to drop weight for the next meet [it is commonly
believed (incorrectly) by High School wrestling coaches that the heaviest wrestler in any weight
class has an advantage, and that the easiest way to be the heaviest wrestler in the class is to lose
weight down to the next class; after all to gain up to the top of the current class would involve
adding fat].
Participants in appearance based sports [see Female Athlete Triad below] are at risk for bulimia.
There is a documented correlation between Bulimia and disfunctional families; a
high percentage of bulimic patients are from disfunctional families, but the percentage of
disfunctional families with bulimic members is not clearly higher than for families without diagnosed
disfunctional behaviors [we don't have data on disfunctional families that have not been diagnosed as
such]. Patients who have been diagnosed as Bulimic tend to exhibit other impulsive behavior as well,
while those diagnosed as Anorexic tend to exhibit other compulsive behavior. Compulsive implies that
the patient will become upset if anything prevents them from (or interrupts them during) carrying out
the activity they feel a compulsion to do; impulsive implies that the patient will immediately
attempt whatever activity they feel an impulse to do, but if prevented (or interrupted) will neither
become upset [just disappointed] nor resume the activity later since the impulse has passed. I infer
from the descriptions of both of these disorders use the expression “exhibit other [compulsive
/ impulsive] behavior” that these disorders are tentatively identified as compulsive (anorexia)
or impulsive (bulimia) behaviors. For the bulimic impulsive exercise, unfortunately, the patient
will probably get an new impulse to exercise as soon as they have time alone to think about their
“need” to lose weight.
Again, to elaborate on some of the signs and symptoms:
1. Bulimia nervosa is characterized by binge and purge eating. On the binge side, I have
seen quotes of up to 3,000 kcal of high carbohydrate food which is eaten rapidly. The binges occur
as recurrent episodes, and once started become compulsive.
2. On the purge side; the purge is now believed to be an impulsive activity brought on by
the feeling of guilt caused by the binge.
3. bite marks: compulsive finger-nail biting produces bite marks along the sides of the
fingernails; compulsive knuckle biting produces bite marks parallel to the fingers at the knuckles.
Bulimic bite marks will be perpendicular to the fingers, and tend to be close to the knuckles. These
bites are not intentional, but accidental due to involuntary mouth movements in response to the
mechanical stimulation of the posterior of the mouth [to induce vomiting].
4. in previous references, the excessive exercise is described as impulsive, but more
recent references suggest that the impulse to exercise is likely to recur any time the patient thinks
about their “weight problem.”
5. the edema (swelling) of the salivary glands is caused by irritation due to the
repeated vomiting.
6. "may be suicidal" WARNING, Will Robinson! ALL evidences of thoughts of suicide
require referral. Too many thoughts of suicide become suicide attempts, and in the current world,
too many first suicide attempts are successful. If a friend expresses thoughts of suicide, encourage
him/her to contact a suicide hot-line where trained people can get the intervention required to save
the person's life.
The treatment of Anorexia nervosa and Bulimia nervosa require a team of qualified professionals,
including, but not limited to, the physician of record, the nursing staff, a trained dietician
[specialized in eating disorders], and the pyschological therapy team. Beyond the psychological
treatment to resolve the underlying psychological issue(s), the goals of the intervention are, at the
least:
(1) to encourage adequate food intake to restore weight to subclinical underweight (or if
possible, low normal range; but not all the way to “normal”). Secondary to
increasing total food intake is to shift the diet to a nutritional sound balanced diet (even if it
doesn't provide RDAs yet).
(2) to encourage reduction in exercise intensity and duration, due to the risks of muscle
tears and stress fractures. Secondary to decreasing exercise, is to reduce calorie demands.
Because of the low effacacy (50%) and high relapse rates (30 to 50%), the
treatments are being continually revised.
Originally binge-eating disorder was described in Nutrition texts as
“binge without purge,” which was considered to be synonymous with “compulsive [over]
eating.” With the observation that 30% to 50% of persons in organized weight control programs
have episodes of binge eating, as a self-awarded reward for meeting a weight loss goal, some authors
began suggesting that this should not be recognized as a disorder, but as an occasional lapse in
compliance with the weight control program. Further investigation has now shown that often the binge
leads to feelings of guilt over the binge [especially when the weight loss appears to have reversed].
The guilty feelings may be transient, but in some personality types the guilt leads to implusive
actions to compensate for the appearance of weight gain [although in all but the most severe binges,
this observed weight gain is not significant]. After this becomes cyclic behavior: compliance with
the program, bingeing as reward for success, guilt, renewed “dedication” to the program,
bingeing as reward for success, … , it may become so close to full-blown bulimia that it would
take a psychologist specializing in bulimia to distinquish between binge eating disorder and bulimia.
For now, we must recognize that binge eating disorder may be a precursor to Bulimia
nervosa for some patients, and treat it as an eating disorder requiring formal diagnosis to determine
the severity of the disordered eating pattern, the prognosis for return to normal, and design of
intervention as needed.
Pica is defined as “the eating of non-food substances.” The oldest references to the eating of non-food substances predate written records. I have yet to do any research on this disorder, so you will have to read the text and determine for yourself how to interpret the signs and symptoms.
female athlete triad, and the un-named male equivalent, affect primarily youth involved in the appearance-based sports (such as gymnastics and figure skating), where the panel of judges awards scores based on the appearance of the performance [which also translates way too often into the appearance of the participant], and youth involved in endurance sports (such as track, skiing, and swimming). These patients exhibit disordered eating patterns, which may lead to technical starvation with respect to some nutrients (some vitamins and/or some minerals). This obviously has the potential to develop deficiency symptoms if the disordered eating patterns persist for a long time. The most severe symptoms reported [in Nutrition texts] is early onset osteoporosis as young as 18 years. The females exhibit delayed onset of puberty, with irregular or no menstral periods. This may be caused by the eating patterns (as currently suggested) or by competition between anabolic steroid production and estrogen production with limited cholesterol due to a lack of red meat fatty acids intake (as previously hypothesized). For males, there is delayed onset of puberty, with reduced semen and sperm count, again which has been hypothesized to be attribuable to competition between anabolic steroid production and testoserone production with limited cholesterol due to a lack of red meat fatty acids intake. This disordered eating behavior comes with a high risk of becoming diagnosable Bulimia nervosa; and I suspect it may be a sub-clinical version of bulimia.
When I first encountered a discussion of this disordered eating behavior [in a Nutrition text sent
to me for possible adoption as the text for this course], my initial reaction was that the author was
making up new eating disorders. Then I remembered the consequences of parents [Yuppie generation]
putting their young children on the then popular low cholesterol diets for reduction in heart disease
risks; which was to produce the first generation of young adults who were not taller than their
parents [later determined to be stunted in growth, since cholesterol is the precursor of Human
juvenile growth hormone].
The primary 'symptom' is a “fear of becoming heavy.” The discussion of
baryophobia contained three statements that lead me to infer that it may be another instance of
parental diagnosis and parental care plan for treatment: (1) the condition may be triggered by
placing young children on adult low-fat, low-calorie diet; (2) the affected children seem to have
been repeatedly cautioned to eat less to avoid becoming over-weight; and (3) nearly all affected
children have parents who are clearly over-weight. If a young child presents with signs and symptoms
of baryophobia, I suspect it is the parents who need to be referred for possible diagnosis of
abnormal thinking leading to potentially treatable behaviors.
other ... reported disordered eating behaviors will undoubtedly continue to appear, particularly in the popular media. This is the “Wiki-generation” which seems to believe that expertise about any subject is conferred by access to electronic communication: the internet allows anyone to author articles on Wikipedia as an expert; text messaging allows anyone to judge the merits of musical performances without having any training in music composition nor performance. There is no reason to belive that diagnosable hypochondriacs won't engage in electronically distributed “reality medicine.”
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