Dear Doctor, Pediatrician, Gastroenterologist, Cardiologist, or OBGYN,
The moment is now. The patient sitting across from you has an eating disorder. This is admittedly a scary moment, on some level. Around 80 percent of you report that you don’t feel adequately informed to identify and diagnose eating disorders. This is actually not surprising, given that many of you receive no training in treating or diagnosing eating disorders during medical school. If you did receive training, the total time likely culminated somewhere between two and six hours. Two to six hours– to understand how to detect, diagnose, and treat the one mental illness that most commonly intersects with the medical illness world (not to mention the mental illness with the highest mortality rate).
I am in no way trying to attack your medical training. I understand that there are only so many hours in the day and days in the year to understand all of the diseases that impact us humans. Rather, I am simply noting how confusing this experience might be for you-when your patient with an eating disorder shows up in your office. I am noting that it is confusing, because I am a psychologist who works with people with eating disorders. And, going by what they so often share with me about your reactions to them, I strongly feel that there is some information that would be valuable for you to understand about him/her-your patient with the eating disorder.
Because, confusing or not, here they are.
They have appeared in your office with a variety of concerns, none of which happen to be a low BMI.
Doctor, here is what you need to know
His/Her/Their normal to above-average BMI is unimportant.
It is actually a non-fact-not worth bringing up at all. You see, the vast majority of individuals who suffer with eating disorders fall into the normal weight range. Please please do not be fooled by the collective societal ignorance that suggests that because someone looks a certain way, they cannot be suffering with a serious eating disorder. Don’t be fooled. You will be doing them a serious injustice if you become tricked by this fallacy.
His/Her/Their blood work can look normal too.
Again, please don’t fall into the trap of taking the facts at face value. Blood work typically tells us very little about the story in the case of these patients. Standard blood work that is typically taken in a first-time doctor visit can be completely normal.
He/She/They may very well come off as the ideal medical patient.
They may talk about their “clean eating,” and strict cardio exercise regimen. Their resting heart rate may or may not be a bit lower than average (which you may enthusiastically attribute to the aforementioned dedication to cardio). Again, don’t be fooled. You have likely been trained with the war on obesity model of healthcare, and hence healthy diet and lots of exercise sound the good alarm bells in your internal checklist. Please understand you’ll be working against most of what you have been taught.
He/She/They may be neither Caucasian, nor 13 years old.
The stereotypes that our society holds about these illnesses are false. Eating disorders do not discriminate. There is no face to them.
If she has her menstrual cycle-great! But that really doesn’t tell us much either.
Amenorrhea has been removed from the criteria section for Anorexia Nervosa in DSM-5 due to these two facts. 1) It was not found to be predictive of low body weight or unstable medical status in enough sufferers. 2) It alienated males from the diagnosis. Which was problematic because, yes males get eating disorders too. Often.
His/Her/Their physical health may be in a very precarious position,
though they may not appear this way on the surface. They may be well on their way to osteopenia, osteoporosis, infertility, dental issues, anemia, delayed gastric emptying, debilitating fatigue, and the list goes on. Again, please remember that they may not present this in your office. Again, please remember that there is no face to eating disorders.
Here is what you should not do:
Do not send this patient away with instructions to “just eat three meals a day from now on.”
Come on doctor, if it were that easy, eating disorder treatment facilities and specialists would not exist.
Please do not suggest diets or “lifestyle changes” to this patient.
Yes, even though they may have a higher-than-average BMI. Yes, even though they said they have been struggling with binging. Don’t prescribe diets.
Do not tell them “you don’t look like you have an eating disorder.”
Please. For the love of God. I cannot stress this enough. If you say this to them, I will most likely burst into your office through the wall and lecture you in person.
Do not tell them that they are “fine,” or at a healthy weight.
Do not utter the sentence “your labs look fine.” I have worked with many clients that have experienced great reservation about accepting help because doctors have told them this. You see, telling them that they are medically “fine” sends a message to an eating disordered mind that one is not sick enough. The thought-needing to become sick enough- is a symptom of an eating disorder. One that is perpetuated, at times, by the medical community.
Don’t get tripped up on common misdiagnoses.
(Hypothyroidism, Irritable Bowel Syndrome, Glucose Intolerance, Anemia.) Listen closely to what they say, and also to what they don’t say. They may very well fit the bill for several of these diagnoses. However, stopping the investigation there and sending them along their merry way will be doing them a grave disservice. You will be adding to their list of medical providers that “missed it,” because they are not the stereotypical emaciated anorexic patient. You will be delaying their likelihood at connecting with a therapist or psychiatrist who will be able to truly assist them. In short, you will be giving them an incorrect, surface level answer that will delay treatment and invalidate their experience.
Doctor, here is what you should do:
Stop, slow down, and listen.
What is going on here? What makes sense in this situation, now that you know eating disorders have no specific physical expression?
Empathize with their experience.
Express interest in their struggle, and validate the fact that what they are going through is difficult.
Suggests that they seek out the advice of an eating disorder specialist.
Provide them with referral options.
Reassure them that eating disorders present themselves in a multitude of ways
Especially if he/she mentions that they don’t not feel as though they have an eating disorder because of their weight or medical condition. Again, encourage them to talk to someone who specializes in this area.
Applaud their bravery.
Be the doctor with the commendable bedside manner. Provide validation for the fact that it takes a great amount of courage to talk about these things. Be straightforward about the fact that the next steps will involve courage as well, but provide them with reassurance that they are brave. They just proved it, after all, by sitting there are talking with you about all of this.
So, doctor, please hear me when I say this:
Your patient-the one sitting across from you-the one with the normal BMI-the star athlete- the one with the normal labs-the one that looks really put together-they may be falling apart inside. The amount of suffering that they are going through is absolutely inconceivable to you or me at this moment. This is because your patient has an eating disorder. And you are now an important domino at the beginning of their recovery path. Please be mindful of this at all times.
Now go forth and be the domino that sets the healing process in motion.
Wow, every single physician needs to read this! I have definitely been in your patients’ shoes. It is why it took me so long to get help. This article is amazing and so so truthful to what people with eating disorders go through each day in the medical field. I am afraid of going to the doctor now because I am terrified of them prescribing a diet which sends ED into a “I told you so” hysteria. There’s a lot of education that needs to take place around eating disorders. This article is a great contribution! I think I will take it into my next doctor’s appointment (when I find the right person and work up the courage to go). ❤️ Thanks for writing this piece, Colleen!
I would add under the heading of menstrual cycle words to the effect of quote below, because I have several times noted that clinicians have been reassured when patients say they are having a normal menstrual cycle but have not also asked if the person is on the oral contraceptive pill and in fact it was the pseudo-menses that occur with the OCP that was happening not normal menstrual cycle!
‘The oral contraceptive pill produces pseudo-menses, it does not provide effective estrogen for bone health and can mask loss of menses from malnutrition.’
Yes this, all of it. The amount of Drs who have thrown it back in my face with all these lines is horrendous. Only ever had luck with one brilliant Dr in my 16 years of struggling with an ED. Scrolled down to comment and had a laugh when I saw he had already commented on the article:)