We all know how hard it can be for a patient with an eating disorder to find the motivation to enter and stick with treatment. (Because I work in a hospital setting, I use the word “patient” rather than client.) Whether you suffer from an eating disorder yourself, are a loved one of someone who has one, or are a clinician, it’s clear that sustaining motivation is one of the greatest challenges.
So many of my patients—brilliant and articulate and sensitive and driven—hear a constant message from their eating disorder that they are “fine” (Aren’t they getting great grades? The star employee? Still able to complete their run?) and in fact should probably restrict more, purge more, go further. It’s an exhausting and deafening message, and it’s incredibly hard to overcome.
Self-esteem and Getting Help
Since self-esteem often runs low at the same time, encouragement to “get treatment because you deserve something better” may not be motivating enough. Well meaning and good primary care providers and emergency department clinicians may accidentally add to this problem by helplessly noting (during the 8 minutes they have available to see a patient) that a patient is “too thin, and has a low heart rate” but the lab work is otherwise fine, so they don’t have a compelling reason to admit to the hospital or leverage to argue to the patient into a higher level of care.
(Picture the hard working therapist, or desperate mother, smacking her own forehead in frustration at how often this happens.)
Helping Patients Gain Motivation
As an internal medicine physician who’s worked with very medically compromised eating disorder patients for years, I am passionate about using my knowledge of medical complications of restricting and purging to help offset the eating disorder voice…give the healthy voice some comebacks…in order to help patients sustain motivation in treatment and hang in there during the dark moments.
It’s actually pretty amazing how few people know about the medical complications of eating disorders…I literally got zero minutes of training in this during medical school and residency…despite the facts that we all know about how the death rate from anorexia nervosa is 6x that of the general age-matched population (and up to 45x for patients who get to the lowest weights), and that medical complications cause over 50% of deaths, with suicide accounting for the rest.
I view understanding of medical complications like a fantastic tool box to use as needed to help a patient renew motivation. By explaining the subtle (and maybe not subtle) ways in which the body is clearly not fine as a result of underweight or purging, I’m able to highlight objective signs of body suffering and give that healthy voice some power. In a disorder this disastrous, deadly, and crippling, we absolutely have to use every tool in the tool box to fight the eating disorder voice.
Let me give you an example: Let’s say there’s a 22 year old woman with anorexia nervosa, restricting type, who continues slowly to lose weight and now has a low heart rate. She continues to exercise regularly (although if she is being honest with herself, it’s getting harder to do so because she’s more fatigued).
At the doctor’s office
Her blood work is completely normal. Her doctor brings up the low pulse. She says, the eating disorder loud in her ears that she absolutely cannot go into treatment and is not ready for recovery, that it’s low “because she’s an athlete.” The doctor may have to shrug and think to herself that maybe the patient is right. Nope! The best thing to do there is have the patient walk across the room or down the hall and back, and recheck the pulse. Almost certainly, it will have doubled (say, from 40 to 80).
Guess what: the slow pulse of a person with an athletic heart will remain slow when exposed to this mild exertion, because an athlete’s strong heart and muscles won’t even notice the difference between sitting and walking. However, someone who’s starving—who’s underweight to the point that her “cave girl brain” has started to make compensatory changes to conserve calories, and who’s exercised off all her great muscle mass because she’s torn it up and not taken in the nutrition to build it back up—will have a totally different physiology.
The brain has put the circulatory system into hibernation, slowing the heart rate, cooling the core body temperature (just like you’d turn down the thermostat in the winter to save money on your heating bill), and lowering the blood pressure. This happens through increased vagal tone, and as a result the majority of patients with anorexia have low heart rates. The way I say it to my patients is, “You’re not fine. You’re so underweight that your body literally doesn’t want to spare a calorie on an extra heartbeat if it doesn’t have to.”
How to distinguish this from the athlete’s slow pulse due to a strong healthy heart?
That walk across the room test. Because the young woman is actually weak due to reduced muscle mass, and perhaps due to reduced cardiac muscle mass, her heart has to pump more rapidly to get her body through this “exertion”…even if she is driving herself to run several miles daily still.
This big increase in the heart rate, even if it’s not formally tachycardia or pulse greater than 100, must be interpreted for the patient as showing that she doesn’t have an athlete’s heart. She has a starving person’s heart. And that furthermore a slow heart rate at rest is evidence of a slowed metabolism, part of the hibernation process, which has arisen out of the low weight, restricted caloric intake, and poor muscle mass. This is a very different message than what’s usually shared, and often makes a big impression!
There are so many examples of the way knowledge of medical complications can be used to help motivate and support our wonderful patients. Many clinicians, myself included, are working to increase awareness of this critical tool nationally.
About the author: Dr. Jennifer L. Gaudiani, MD, CEDS. is the Associate Medical Director at the ACUTE Center for Eating Disorders at Denver Health
- Mehler, Philip S. and Andersen, Arnold E. Eating Disorders: A Guide to Medical Care and Complications. Baltimore: Johns Hopkins University Press, 2010. Print.
- Rosling AM, et al. Mortality of eating disorders: a follow-up study of treatment in a specialist unit 1974-2000. Int J Eat Disord 2011;44(4): 304-10
- Papadopoulos FC, et al. Excess mortality, causes of death and prognostic factors in anorexia nervosa. Br J Psych 2009;194(1):10-17.