Public awareness of eating disorders is widespread. Many documentaries and talk shows have focused on anorexia nervosa and bulimia nervosa, so that most laypeople are familiar with the terminology. This is not to say that the general public is well informed. Often having a little information is worse than having none at all.
Most of the documentaries or talk shows I've seen on eating disorders follow case histories of anorexic or bulimic patients, and the commentary is usually provided by experts on the subject, namely psychiatrists. I recall one Oprah show that featured several anorexic patients and their therapists. Some of the patients also had their parents with them. Conspicuously, there were no medical doctors among the experts, nor was any mention made during the entire show that anorexia can be caused by many medical disorders.
Some therapists boasted of successfully treating their patients for several years, stressing that "beating anorexia can take years of therapy." Some of the patients talked about the "anorexic voice", while others mentioned their low self-esteem. Some parents admitted that they were partially to blame for their daughter's behavior, and most agreed that the social pressure to be thin was the root problem. Perfectionism, obsessive compulsive tendencies, and low self esteem were unquestionably seen as causal factors. No mention was made of digestive problems, or other possible causes of poor appetite, nor were any medical tests identified that might provide a differential diagnosis. This is quite amazing, since the majority of anorexic patients suffer from many digestive problems, including constipation, bloating, epigastric pain, and nausea.
I've seen several documentaries on anorexia nervosa, and again, no mention is made of any physical disorders that could cause anorexia. The predisposing factors of perfectionism, obsessive compulsive disorder, and social pressure to be thin are accepted unquestioningly as the root cause. Any mention of medical issues only dealt with complications of malnutrition or electrolyte imbalances due to purging.
Unfortunately, the net effect of these public awareness campaigns has been to exacerbate the epidemic of anorexia nervosa. In developed countries, young people, especially women, are dieting and participating in strenuous sports in numbers never before seen perhaps in the history of mankind. This in and of itself is not a bad thing. However, a significant percentage of these young people will have pre-existing physical disorders that may prevent them from developing a suitable appetite or from absorbing the necessary calories needed for their increased energy expenditures.
These disorders may not be readily apparent, and the individual concerned likely will not realize they are ill. Many digestive disorders are chronic, and allow the sufferer to adapt to the mild discomfort as they gradually develop. The only noticeable symptoms may be irritability, occasional mild epigastric pain or nausea, moodiness, food fussiness or irregularity. Parents will often dismiss these symptoms as whining or due to poor diet. Often it is not seen as warranting a trip to the doctor. If a physician is consulted, most of the time these symptoms are attributed to stress, lack of fibre, growing pains, or behavioral problems.
The individual starting the new fitness regimen may be of average weight or even be overweight at first, since their relatively low energy demands would not have exceeded the caloric supply. The vast majority of people starting a diet or a fitness program will have to work very hard to achieve their weight or fitness goals. The person with the digestive disorder, however, may find it very easy to lose weight, since their appetite has never been very good, or they may not be absorbing enough nutrients from their food.
At first, these individuals may be encouraged by their success, and if they are participating in sports, their strength-to-weight ratio may increase rapidly as their body mass drops and muscle strength increases, giving them improved performance. However, in time, the prolonged deficit in caloric intake may eventually result in an advanced state of malnutrition. Since this happens gradually, the anorexic individual adapts to the starvation and still has high energy levels and may become hyperactive (see Starvation Response page).
Here is where the public awareness campaigns backfire. These well intentioned efforts to inform the public about eating disorders have made the average layperson believe that all anorexia is a result of mental illness, namely an obsessive-compulsive disorder. Few, if any of these educational efforts have made any mention of physical illness being a common cause of appetite loss. So the parents or friends of an anorexic individual immediately suspect anorexia nervosa. The anorexic individual doesn't complain too much of pain, since they have had many years to adapt to their condition. The family doctor will generally tend to agree with the suspected diagnosis of AN, because the behavior seems to fit all the diagnsotic criteria. Normally, with only a quick physical exam, and possibly a blood or urine test, the patient is referred to an eating disorder specialist.
Once enrolled in an eating disorder program, there will generally be very little diagnostic testing performed to look for any underlying physical causes of anorexia. Blood tests may be run to monitor electrolytes or detect any dangerous complications due to malnutrition. Treatment will consist of nutritional counselling, behavioral therapy, and regular monitoring of nutritional status. The patient will be put on a rigid mealplan and scheduled for regular visits to the eating disorder clinic and the doctor. If the malnutrition is severe, the patient may be admitted to hospital for force feeding or tube feeding. If the patient is a child, this will normally be on a pediatric ward, whereas an older patient may be admitted to a psyche ward.
For some patients, counselling will work. For others with serious unidentified medical disorders, it may not. For the outpatient, the inablitiy to eat enough and to gain weight may result in escalating family tensions, especially around mealtimes. All family members will be trying to encourage the anorexic person to eat. The person may want to eat, and may feel hungry, but as soon as she takes one or two bites she loses her appetite or starts to feel sick. In an effort to make it look like she's eating, she may push her food around the plate or eat very slowly, one pea at a time. If the pressure to eat is too intense, she may force down her meal, and immediately head for the washroom to induce vomiting. If this tactic is discovered, she may resort to doing this in secret in her room. She would prefer to eat by herself, where she doesn't experience all this pressure, and so she may make up excuses to avoid eating with the family.
The anorexic person may not know why they're not hungry, or why they feel full after only a few mouthfuls of food. No one in the family understands what's happening, and some think she's just being stupid.
The original goal of the exercising or dieting may have been to lose weight or to improve performance in competitive sports. It wasn't to see how low her weight could go. But the patient now doesn't know why she's acting this way or why she's just not hungry. She may invent reasons for her behavior, and say she just wants to lose a few more pounds. And she may actually want to lose more weight, because the bloating she's experiencing may make it hard to get her pants on some days. She may look in the mirror and see her bloated tummy, and think she must do more abdominal exercises. If her original intention was to look like some supermodel, she may become extremely frustrated because as her weight drops, her bloated stomach just looks even bigger by comparison. She may also experience terrible constipation (many biliary tract disorders can cause severe constipation) and start using more and more laxatives to keep things moving.
As you can see, all the public awareness initiatives have failed the patient with an underlying digestive disorder. What percentage of anorexic patients will have these underlying disorders? 1%? 10%? 50%? 100%? We will not know until all have received the proper diagnostic testing. I would suggest that the majority of severely malnourished anorexic patients have some underlying medical cause for their loss of appetite, even though they may claim to be avoiding food wilfully and seem intent on losing more weight. Few will ever find out, if they trust psychotherapy to cure their medical problems.