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19Jul

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 www.bulimia.com)
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.
  

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