Eating disorders have the highest mortality rate of any psychiatric illness, but frequently go undiagnosed because of  societal misconceptions that often pervade clinical practice.

Approximately 0.9% of women and 0.3% of men have a lifetime prevalence of anorexia nervosa. An estimated 1.5% of women and 0.5% of men suffer from bulimia nervosa and about 3.5% of women and 2.0% of men struggle with binge eating disorder at some point during their lifetime (Hudson et al., 2007).

These statistics are suspected to be much higher as eating disorders are generally secretive illnesses, particularly in those with anorexia nervosa who feel an artificial sense of control, are in denial, and resist treatment.

We need to be able to properly detect these deadly illnesses as early intervention correlates with improved prognosis. The likelihood that a patient with an undiagnosed eating disorder will come up in clinical practice is very high. While we cannot possibly become experts in all mental health related conditions, we can become trained in detecting disorders outside of our scope of practice and ethically refer out to specialists who practice evidence-based treatment for eating disorders.

Just as we routinely screen for substance abuse disorders, eating disorder inventories need to become the standard protocol of biopsychosocial assessments. A simple screen can be done by administering the Eating Disorder Inventory (EDI-3) or the Eating Attitudes Test (EAT-26) to new patients as part of the intake process.

Myths That Pervade Clinical Practice

Our mainstream culture makes it seem as though eating disorders specifically target white affluent teenage girls when in reality, eating disorders do not discriminate and can afflict anyone regardless of any age, gender, sex, race, ethnicity, and/or socioeconomic status.

For example, there is a significantly higher incidence of bulimia nervosa and binge eating disorder in Latinos, Asians, and African Americans. Anorexia nervosa appears more common in non-Latino Whites. (Marques et al., 2011).

Not being aware of this trend may skew our clinical judgment in overlooking an individual’s eating disorder because they do not meet the cultural stereotype. More dangerously, we may dismiss the seriousness of a patient’s eating disorder because he/she is not significantly underweight.

While it may seem intuitive to believe that the more underweight an eating disordered individual is the sicker they are, this is not the case. Eating disorders are mental illnesses with physical manifestations and these physical manifestations can vary from patient to patient. Many of our patients, for instance, may be on psychotropic medication that induces weight gain or have co-occurring metabolic disorders like hypothyroidism.

Unlike the messages we are told by the dieting industry, weight loss is far more complex than simple caloric deficits. Patients with eating disorders often have considerably slowed down metabolisms because the human body will do whatever it needs to do to survive.

Eating disorders come in all shapes and sizes and can kill at any weight because of various medical complications regardless of how long that person has suffered. It is crucial to understand that BMI is not indicative of a patient’s psychological status or medical instability.

Detecting Eating Disorders

There are many biological forces and psychosocial dynamics that place an individual at risk for developing an eating disorder, such as their personality type, how they generally react to stress and history of mental illness. Eating disorders are essentially maladaptive ways of coping with life transitions, loss/grief, traumatic experiences, co-morbidity, and/or an unstable sense of identity.

They are centered around control. Losing weight may be an attempt to literally disappear because of intense feelings of worthlessness. A patient may metaphorically run away from his or her problems through compulsive exercise. Purging can be a way to throw up feelings of guilt. Poor body image is typically a reflection of feelings of inadequacy.

It is important to note that these are common themes within the eating disorder population and that each of our patients’ experiences are unique. The severity of a patient’s eating disorder should be assessed on a myriad of factors, including their current mood, psychosocial stressors, level of functioning, estimated daily caloric intake, average amount of exercise and frequency of purging and/or using laxatives.

Eating disorder patients must undergo a thorough medical evaluation, which includes physical health observations, any medical complaints that the patient has, a comprehensive blood panel, urinalysis to screen for ketones, an EKG for cardiovascular complications and orthostatic vitals to check for orthostatic hypotension.

Eating disorder patients often have electrolyte imbalances as evidenced by abnormal levels of phosphorous, potassium, and/or sodium. One episode of purging can rapidly deplete these essential electrolytes, resulting in sudden death.

The presence of ketones in urine signals that their body has gone into starvation mode.

Gastrointestinal issues such as severe constipation and bloating are also common in patients with eating disorders.

It is also crucial to assess for suicide as this population is at high risk, especially those with co-morbid mood disorders. One out of five anorexic deaths are because of suicide (Arcelus et al., 2011).

Measuring a patient’s level of suicidality can also be helpful in determining an appropriate level of care.

Ethical Duty to Refer to a Specialist

If you suspect a patient may have an eating disorder and this is population is outside of your scope of practice, you need to ethically refer out to an eating disorder specialist. This population requires a multidisciplinary team approach consisting of a therapist trained in eating disorders, psychiatrist, medical provider who is knowledgeable about the associated physical health complications and a nutritionist.

Consider implementing a routine eating disorder screening in your practice. The earlier we can detect these deadly illnesses, the sooner people can get the help they need. Remember that early detection combined with proper linkage improves a patient’s prognosis of achieving full remission.

References

Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality rates in patients with anorexia nervosa and other eating disorders: a meta-analysis of 36 studies. Archives of General Psychiatry, 68(7), 724-731.

Hudson, J. I., Hiripi, E., Pope, H. G., & Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the national comorbidity survey replication. Biological Psychiatry, 61(3), 348–358.

Marques, L., Alegria, M., Becker, A. E., Chen, C., Fang, A., Chosak, A., & Diniz, J. B. (2011).

Comparative Prevalence, Correlates of Impairment, and Service Utilization for Eating Disorders across U.S. Ethnic Groups: Implications for Reducing Ethnic Disparities in Health Care Access for Eating Disorders. The International Journal of Eating Disorders, 44(5), 412–420. http://doi.org/10.1002/eat.20787