Q: If anorexia is caused by medical illness, why do so many anorexic patients recover through psychotherapy?
A: We don't know how many cases of anorexia nervosa are actually due to medical illness, since many patients have not had adequate diagnostic testing to determine this. If the patient meets all the diagnostic criteria outlined in DSM-IV, many physicians naively assume that there is no further need to look for underlying disorders. Many chronic medical disorders are either temporary, transient, or may go into remission or completely clear up on their own, so recovery does not necessarily mean that the patient did not have a medical illness at the time of their eating difficulties. In cases where the patient has a mild chronic illness, nutritional counselling may be enough to effect weight gain. Cancer patients who experience anorexia are able to prevent excessive weight loss by paying close attention to their food intake and eating habits. For an interesting overview of how cancer patients do this click here. It is sobering to acknowledge that anorexia nervosa has the highest morbidity and mortality rate of any psychiatric disorder. It is entirely possible that most, if not all of the cases that progress to the point of requiring hospitalization due to malnutrition, have an underlying medical disorder as the root problem. Only extensive diagnostic testing can confirm this.
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Q: If medical illness can cause all the behaviors of anorexia nervosa and bulimia, why don't the reputable websites mention this in their literature?
A: I also find this extremely puzzling. Anorexia is a common presenting symptom of many illnesses, and yet few websites or books mention this fact. There is a possibility that vested interests blind some therapists to these realities. Also, the behaviors associated with AN and BN at first seem quite bizarre, and therefore it is understandable that these behaviors would not be interpreted as due to complications of physical illness. The patient might be fully convinced they need to lose more weight and be exercising excessively despite barely eating anything. They may have become vegetarian. The moderate success rate of eating disorder programs may also convince some program organizers that they indeed have the solution to the problem.
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Q: Why don't eating disorder clinics do the diagnostic tests specified in your website?
A: Most eating disorder clinics make no attempt to challenge the original diagnosis of an eating disorder. It is not in their best interest to do so. Therefore, the most critical player in identifying and treating the underlying disorder is the patient's GP, who generally will not realize that all the behaviors of AN and BN can be triggered by medical illness. Most eating disorder programs are eager to accept new patients, and once the diagnosis of AN or BN is made, they will only focus on psychotherapy, nutritional counselling, and monitoring the patient for complications due to malnutrition or electrolyte imbalances. It is possible that some therapists do realize that there are many cases of anorexia nervosa or bulimia nervosa that were incorrectly diagnosed, but few have enough courage to publicly admit that this is this case. To do so could jeopardize their position and possibly their entire professional future.
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Q: You're obviously not qualified to comment on causes of eating disorders, as you are not a medically trained person nor trained in psychiatry. What makes you so arrogant that you think the experts are wrong?
A: I hope I do not come across as arrogant. However, I as a parent of an anorexic child watched the entire scenario of anorexia and weight loss unfold. Few therapists can claim this. I have known my daughter since she was born, and I understand her personality, her idiosyncrasies, her character, and I know her values and upbringing. I witnessed the development of her food fussiness. I played a large part in encouraging her to pursue excellence. I know she was not abused. She is my friend. I care about her deeply. Most parents of anorexic children could say the same. Not one of the doctors or therapists involved in her case could make any of these claims. The therapist is forced to make all sorts of assumptions about the patient.
I witnessed how every doctor (except the surgeon who operated on her) and therapist was completely wrong, and totally misinterpreted her behavior. I observed and experienced first hand how incredibly difficult it was to obtain proper diagnostic testing and appropriate treatment. Only by going against every doctor's and psychiatrist's advice was my daughter able to get the help she needed. I personally had to arrange the medical tests necessary to correctly diagnose her illness. One doctor involved with her case reported our family to social services citing her as a protection risk. I travelled the 4000 miles with her to see the only doctor who knew what to do. I witnessed her entire recovery. I have discovered several other cases of misdiagnosis, and have heard rumour of many more. I observed terribly flawed and irrational diagnostic methods, and discovered fundamentally flawed beliefs among virtually every doctor and therapist involved in her case. At the root of all these deficiencies was the entrenched belief among all health professionals involved that anorexia is due to mental illness.
In this information age, the latest medical research is at our fingertips. In many cases, patients can acquire more knowledge of their disorder in a few hours than their doctor has in their entire career. Unfortunately, they can also acquire a great deal of misinformation just as easily.
In countries like Canada, where most GP's have been reduced to practicing turnstile medicine, doctors simply do not have time to investigate the various ailments of their patients. They are also under tremendous pressure from the medical insurer to limit the number of diagnostic tests done. They also, of necessity, must follow rigid protocols to avoid litigation and professional discipline. Being human, they harbor biases and beliefs that may predispose them to prejudge or misdiagnose a medical disorder. This is perhaps the crux of the problem, since the GP plays the most important role in directing the patient to the proper specialist. If the GP directs the patient to an eating disorder clinic rather than first to a GI specialist, often the patient's fate is sealed. It is then unlikely the patient will receive adequate diagnostic testing there, and complaints of abdominal pain and appetite loss will generally be dismissed as being of psychological origin.
In the end, it is unfortunate that it takes someone from outside the medical or psychiatric community to raise awareness of these glaring deficiencies. It is not unexpected however, since anyone inside these communites would risk not only their professional future, but would be the object of ridicule and much criticism. I myself have no vested interest in medicine or psychiatry, other than the moral obligation to inform anorexic and bulimic patients and their families that the conventional wisdom is flawed and may jeopardize their health, their family, and the patient's life.
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