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Dr. Bob is Robert Hsiung, MD,
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Posted by CareBear04 on January 19, 2008, at 11:28:48
Hi everyone-- just something I have been confused about. The way I understood it, an ED requires both actual actions/inactions like restricting or bingeing, plus the intent of controlling weight driving those actions. Under this definition, not eating well due to depression or anxiety wouldn't by itself qualify. A couple of months ago, though, my pdoc said an ED is determined based on the objective symptoms. We were sort of in the middle of a heated exchange, so I didn't ask him about the need for the subjective component.
What are your thoughts? Do actions without intent count as an ED?
Thanks,
CB
Posted by Racer on January 19, 2008, at 21:55:29
In reply to Does an ED require a mental component?, posted by CareBear04 on January 19, 2008, at 11:28:48
That's a hard question. The problem has to do with denial, since a lot of people with anorexia deny that they have any intention of keeping their weight down, or that there's a problem with their eating patterns, etc.
One of the symptoms of depression is a loss of weight without intent. That means that in someone with depression *and* an eating disorder, the waters are pretty muddy. Anxiety can lead to weight loss, too. For me, high enough anxiety can lead to emesis, which can look like a different sort of eating disorder than the one I actually have. So, weight loss can be a sign of depression or anxiety.
On the other hand, low enough weight is also a sign of an eating disorder. Binging followed by inappropriate compensatory behaviors is an eating disorder. Certain patterns of thinking about one's body or one's weight are signs of eating disorders.
It's hard to tell just how much of a clear psychological component there must be for a diagnosis of an ED. Also, it's pretty easy to tell a doctor, "nope, not interested in keeping my weight down, I don't think I'm fat, I'm just not that hungry/food upsets my stomach/etc." Therefore, a lot of doctors make the dx based on actions, without worrying about intent. In fact, some doctors will make the dx based on weight criteria in the absence of clear physical causes.
How did this come up? I'm guessing you're hearing an ED suggested for yourself? Sometimes we're not really aware of our own intent in these things -- that's what makes EDs so difficult all around.
Hope that helps.
Posted by CareBear04 on January 21, 2008, at 18:24:26
In reply to Re: Does an ED require a mental component?, posted by Racer on January 19, 2008, at 21:55:29
thanks racer. at least i understand how the question can be answered both ways now.
yes, the question is based on a suggestion that i have an ED. my pdoc hasn't raised the issue again since. it actually wasn't his own observation. he was talking to my pcp who mentioned that he had hospitalized me for malnutrition and that he suspected an occult ED. i was surprised because i wasn't aware of a hospitalization for malnutrition. he has hospitalized me twice, and the first time had no connection to eating at all. the second time, i guess, could be tied to nutrition. i have a history of orthostatic hypotension not clearly tied to whether or not i'm eating a lot. i was walking into the clinic for a follow-up and passed out, slamming my chin into the ground. i got stiches and fluids in the ER, but when my blood sugar was still low later, he admitted me overnight for observation.
being stressed really messes me up-- can't sleep, can't eat, constantly tense and on edge. i think part of the weight loss has to do with being too busy to make time to eat properly and, consciously or not, putting nutrition last in terms of priorities. eating when i'm tense is just functionally unpleasant, too, in terms of quesiness, swallowing, disgestion... when depressed or manic, i tend to lose weight, too, either because getting food and eating it seeems to require too much effort or because i'm so all over the place doing a million things.a few years ago, i had an upper endoscopy that resulted in esophageal lacerations. i was prescibed vicodin and percocet for pain, but they didn't help much and i couldn't eat or drink much at all. the painkillers caused my mood to plummet, but the weight loss threw off my metabolism so that i got lithium toxic. after a few days in the medicine unit, i was transferred to psychiatry to restart lithium safely with close monitoring. even though my family and my pdoc at the time affirmed that they didn't think i had an ED, the inpatient team was convinced i was anorexic. their diagnosis was based on very low weight and certain lab results like borderline-low potassium and very low prealbumin on admission. the whole hospitalization was a mess for a lot of reasons not relevant to this thread, but after i was discharged, i was able to regain a lot of the weight even though it took awhile. since then, i've been in the hospital several times for medical or psych reasons, and though i've had nutrition consults, but none of the drs have suggested or noted any suspicion of an ED.
what you said about factoring in intent as part of diagnosis was interesting. i guess if only objective standards are used, i would qualify as having an ED since my eating patterns and weight are troubling at times. but i'm not sure what the outcome would be under the objective + subjective intent standard. if intent is defined as purpose [of losing weight], i don't think i have that. but if it includes knowledge that weight loss is very likely, i do know that; i think i just don't consider nutrition to be as or more important that other commitments to shift time from them to eating.
any thoughts?
thanks,
cb
Posted by Racer on January 22, 2008, at 1:52:42
In reply to Re: Does an ED require a mental component? » Racer, posted by CareBear04 on January 21, 2008, at 18:24:26
I do have a few thoughts...
First of all, let's make a distinction between two things: Eating Disorders, as defined by the DSM; and eating disorders, which I think you've pretty well described -- your eating patterns are disordered. In that sense -- which, really, is what counts as far as health goes -- you're exhibiting disordered eating patterns, which means you've got an eating disorder, even if it doesn't exactly match criteria set forth in the DSM.
For what it's worth, I've known a number of women who swore up and down they didn't have an eating disorder -- they just weren't hungry, and when they did eat, it just made them sick. No eating disorder, since they didn't put their fingers down their throats. The very first step towards doing something about their problem was to recognize that it was a problem, and sometimes that's the hardest part.
In fact, denial is a huge part of many eating disorders. In my own case, I can say, "I am anorexic," but I don't entirely believe it. (Of course, right now it's absurd to say it, since I'm fat as a cow, but that's beside the point.) When I first entered treatment, I truly thought that I'd be found out as a fake, and that I could just -- eat. It took quite a while for me to recognize that I couldn't just eat, that I wasn't just fooling everyone, that I really did have an eating disorder. Even now, I still go through that -- it's actually harder, since my weight is up, because now I know no one would believe me that I have an eating disorder.
At any rate, one thing I know is that eating habits affect mental health. At my thinnest, I think I was close to psychotic -- I remember some of the things that I thought at that point, and they all seem really crazy to me now. I also know that not eating properly leads to all sorts of other psychiatric symptoms, none of which I recommend to anyone who wants to feel human.
I hope that this is helpful, and by helpful I mean that it starts you thinking about getting treatment. I hope that you'll discuss this with your pdoc, and see what he has to say about treatment for it. Even if you don't fit one of the classic categories, you certainly fit EDNOS, and your eating is disordered, which isn't to your benefit if you want to find remission for the bipolar. (Medications will work much better if you do something about your eating...)
Good luck, and I hope that helps.
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