1MEN’S AND WOMEN’S HEALTH – OCTOBER 11TH, 2007

NATUROPATHIC APPROACH TO EATING DISORDERS AND BODY IMAGE DISTURBANCES

LECTURE 11
• Slides are not in order.
• Anorexia: highest mortality rate of any psychiatric disorder.

Risk for death:

• Daily vomiting/binging: metabolic alkalosis, dehydration, electrolyte loss. Hard to find this out, guilt and shame around
eating disorders. Always check their BP, weight (if they don’t refuse).
• Bulemia: can get gastric dilation, stomach rupture.
• Vomiting can present in anorexia. If they eat more than they think they should, will compensate with vomiting,
laxatives.

Symptoms found in patients with Anorexia Nervosa

• Feeling of fullness: this is REAL. Stomach has shrunken, motility has slowed down. Slower transit time. Bitters
helpful with this.
• Leg pains: red flag. Related to electrolyte balance. Sign that their balance is off.
• Infertility: be aware of their weight. Women seen in fertility clinics: some that are not ovulating may have undiagnosed
eating disorder.
• Polyuria: don’t have strong kidneys: start to weaken. Will drink a lot of water, eating a lot of fruit and vegetables.
• “Refeeding syndrome”: if they take in too much food too quickly: increase blood volume, strain on KI, KI failure

Signs of Anorexia Nervosa:

• Sialadenosis: enlargement of parotid glands
• Lanugo: growth of fine hair due to hypothermia. Goes away with weight gain.
• Yellow skin, esp. on palms (more visible in Caucasians): Keratenemia, related to LV function. Will start to smell like
feces in later stages: bilirubin is coming through the pores.

Temperament of AN (generally speaking)

• Fearful of intimacy: or may be in relationship, but may not have enjoyment of sex
• Hesitant to have new experience,

Diagnostic criteria for Bulimia Nervosa

• Recurrent.
• May vomit/purge up to 15-20 times/day.
• Don’t have prolonged starvation/weight loss.
• Weight remains stable or can increase.
• Keep some food down, and calories are absorbed quickly.
• More violence/impulsive re: bulimia. May be linked with self-mutilation: cutting breasts, abdomen, arms, legs.
• May have impaired gag reflex: use other things like toothbrush, washcloth: risk of choking.
• “Dramatic”: very labile/reactive personality. Eg. : Dr. G did acupuncture on bulimic patient, LV3, jumped off table,
crying, ran out of office. Why? She wanted Dr. G to follow her, attention-seeking behaviour, guilt induction.
• Other behaviour: might repeatedly cancel appointments, frantic messages. Dr. G. won’t work with them unless they
also have a counsellor/MD. Know your limits. There are others that are trained to help them.
• Idea of letting go of behaviour is terrifying as well: relationship to addiction, can be “best friend”, part of identity.

Symptoms found in patients with Bulimia

Swollen cheeks: due to electrolyte imbalance (?)

Signs of bulimia nervosa

• Russell’s sign: callouses on hand from repeated trigerring of gag reflex
• Perimolysis: enamel erosion, will see this on the back of the teeth (acid is coming this way). Dentists and hygenists
will likely ID, but may not ask.
• Gingivitis, caries common

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• Periorbital petechiae: due to force of vomiting
• Injected sclera: due to vomiting: usually see this within 1-2 hours after vomiting.
• Lots of signs, but most are non-specific.

Temperament of BN
• Need external acknowledgement. Anorexia, don’t care as much about what others think.
• High risk behaviours: drive fast, don’t care if they crash
• Dependent on praise, will give up easily. Perfectionist personality, will stop if they can’t do it right the first time.
• (Be careful to not use praise with anorexics: don’t tell them that they look good, have gained weight.)

Physical examination – suspected or known eating disorders

• Assess hydration through skin turgor
• Weight and height: ask patient if it is okay if you weigh them.
• Cardio-vascular, EKG, important in chronic cases. Auscultate the heart and palpate the wrist at the same time.
Check that they correspond. If there is a difference, irregularity, RED FLAG FOR EKG. Indicates that there is
irregularity. Assess by counting how often it is happening. Regular irregularity (eg. Every 10 seconds). Irregular
irregularity: happens randomly over time you are assessing.
• Abdominal exam
• Teeth and gums.
• ALWAYS DO VITALS

Case: Anorexic patient, female 27 years old. 80/60, 48bpm. Looked so weak. Hadn’t been to doctor in 6 years. Told her
she had to go that day, went to hospital and held for 3 days, risk of heart failure due to electrolyte imbalance.

Another case: anorexic patient, 82 lbs, will talk about it later. Is taking heroin, risk to heart.

Recommended Lab Tests

• Starred ones: try to get these done if they have access to GP. If requesting, attach info: GP may not have specific
training in eating disorders.
• DEXA (bone density): they may have started to lose bone mass. Think of this if they haven’t menstruated in a year.

Cardiac Complications
• Acrocyanosis: cyanosis in extremities
• Calf pain: hypokalemia: major cation, small window, can supplement with potassium. Severity depends on frequency
of purging/vomiting.
• Dyspnea d/t alkalosis

Heart changes (picture)

• Overlap of valves, disproportionate. Don’t close properly, will start to hear clicks.

Factors for increased cardiac risk

• Co-morbid disorder (DM) increases risk
• Older age: if they have been bulemic for many years. Cumulative stress on body.

Effects on reproductive system

• GnRH release goes to “pre-pubetal” pattern (low intake of precursors?)
• Cysts on ovaries (Not PCOS). Body is shutting down reproductive system.
• Will lose secondary sex characteristics. “Boyish” body, flatter chest, less hair growth, hip development.

• 60% of women seen in infertility clinics with oligomenorrhea: had eating disorder. (study)
• Fats seem to be important factor in ovulation.

Factors contributing to the development of osteoporosis in AN.

• Cortisol is higher, esp. in AN.
• Even if they are doing weight bearing activity (eg. Running), may not be enough to compensate.
• Symptoms go away once they start eating again.
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• Fracture risk, may present with bone pain.
• Thyroid: get euthyroid syndrome: normal thyroid that may start behaving abnormally due to low body weight.

GI system:
• Especially with use of laxatives, nerve plexi become numb, hypofunctioning. Cathartic colon syndrome: no function of
colon. Does not typically resolve.
• Slow-moving bowels, persistent. Very hard for them to know they have food sitting in their body.

Flow chart: re bulimia

• Disturbed satiety: sense of satisfaction. When they eat, there is a delayed response in feeling full. Don’t have a
sense of feeling full: keep eating.
• Binge eating gives a high. After eating, get depressed, vomit, get a high, then feel guilt.
• Study of control/bulimic individuals, look at CCK release: they have less released. Physiological change.
• Bulimia: open to psychoeducation: may want to know what it happening in their bodies and this may help them heal.
Anorexics may not be as open to this type of work: already have a lot of information.

• In practice, most likely seeing patients that WANT to change. See some with undisclosed disorder, start by
establishing trust. Then talk indirectly about how they relate to food, body image, they may start talking, feeling safe.
If you are very concerned for their health, may need to be more direct. Risk: they may not come back, although you
may have planted a seed. They may deny it, be offended.
• In family history, may inquire about history of eating disorders… may give them space to disclose.

• Toronto General: In-patient eating disorders clinic. Supervised meals. Food may not be healthy food… Supervised
afterwards to make sure they don’t purge. Monitor heart rate in/out of bathroom, not working out in bathroom.

Red Flags
• High frequency: if they say they purge, have to find out how often. Find out how they do it as well, other risks?
• Best way to get away from shame: talking about it. Painful at first, but gets lighter and starts to dissipate.
• Peripheral edema, especially around lower legs (d/t KI failure)
• Leg cramps, chest pains…

Where to start?
Disclosed:
• Assess stage of awareness of their condition, what the risk is, support system. Have they told anyone? See therapist,
GP? You might be the first person they have told.

PART II
Trauma: separation of spirit from body and mind.

CNC theory: confirmed negativity condition: Negative mind constantly punishing them telling them to exercise, not to eat.
“The secret language of eating disorders”: written by person who developed the CNC theory (being sued)

Trauma and the loss of spirit

• Dissociation: can feel the physical pain, but their mind leaves. Too painful to mentally experience so they separate.
Careful not to probe too deeply, may revert to this state.
• Mind/ego becomes a thing in itself.
• Ego: always wants more, is never satisfied. Nothing is ever good enough. Constantly judging and pushing. Negative
self-talk. (Taming the Monkey Mind –book). Avoidance strategy, to get away from pain.

Binges: an attempt to care for yourself when you don’t know how to. Not healthy, but a coping mechanism.

Effects of Trauma
• “prosecutor” should read “persecutor”
• Incredibly aggressive negative mind. Living with this.

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• Flow chart
Theory behind etiology of eating disorders. Can substitute any addictive behaviour in the box that says “bulimia”
• How do you shift the pattern?

• Identification with trauma: if I am not thin, I won’t be liked. This will become what they live for.
• Like being attracted to people that match what you are used to (eg. Family relationships), even if they aren’t good for
you. Like relationship to addition, feels very comfortable, familiar, like home.
How do they relate to other people? This is a reflection of how they relate to themselves.

Inner beliefs:
• Food represents energy, yin energy, it is nurturing. Reject this. Feel that they need nothing/no one
• Deep belief that they aren’t worthy, don’t deserve anything
• Don’t believe they are attractive, have good qualities.
• Beliefs can come from parents, their attitudes to weight, food.
• Film: Through Thick and Thin: interviews with women with bulimia, anorexia. Dr. G. has a copy.

Energetic psychospiritual perspective of addiction

• If they are feeling low, will do something that will cause a spike: binge, purge, run, use drugs. Uncomfortable for them
to sit with their emotions. Technique: ask them to sit and see what happens, be with their emotions. Hard: have to
face where they are at, becoming present. Simple technique. Idea of meditation can be daunting for people. This
might be a good place to start.
• Immediate satisfaction: dissipation of uncomfortable feeling.
• There are layers of emotion: fear. What are they afraid of?

Recovery:
• If you have a good relationship with patient, this is key. Have to keep confidentiality, not disclose to parents, partner
unless they are okay about his. Patient needs to know you are on their side.

• No diets or restrictions! You are adding to their diet

Main treatment goals

• Assiste them to decrease fear of food/living.
• Increase connection to self. Make a list of things they want to do to be healthier and focus on one thing. Make it a
specific goal. They are usually vague to start. Can interpret this in many different ways, not concrete. Help them to
focus on one thing, they will feel better about themselves. Keep it simple and specific.
• Making a commitment to yourself. A vow to yourself.

Process of recovery
• Mourning is a part of the process of recovery. Don’t start with the disappearance of symptoms.
• Someone can spend much time in the early stages.
• May have most pain at beginning of process: they no longer have a distraction from the stuff they were distancing
themselves from.
• Reassure them that feeling bad at beginning is normal.
• Exercise might help, gentle yoga. Greater sense of self-worth, weight gain.
• In order to get better, they have to be willing to think differently.
• NLP: neurolinguistic

• Snakes and ladders: healing is not linear. Will have ups and downs.
• “Goal” may be daunting, try “intention” instead.
• Try to ground the goal. Concrete, specific.
• Journalling: Patients may not like it. Try writing letters, to body, from body.
• Addictions are around “hungers of the soul”. When you are not fed in other aspects, develop patterns that are not
healthy.
• What do you like doing, look at these things. Is there an area of life that is not being addressed?
• Try to stifle something, it pushes back harder. Don’t squelch the negative mind, just provide more positive thoughts.

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• Gentle exercise is important. Movement is what is important. Dancing, stretching, run/walking
• Exercises to ground self: lie on grass, sitting, breathing.

Case #1: Weight gain is common in anorexia. Gained 2-3 pounds per week.
Cutting is big concern. Self-mutilation: the only way that they can get release from pain. Where is she cutting?

Case #2: Severe erosion of esophagus, potentially very serious.

Given Holter monitor for heart rate
Decreased exercise to 60 minutes.

Case #4: Parents academics, had lots of pressure to be a good student. Went to private school, high expectations. No
trauma/abuse. Perfection.
Really enjoys sex, likes touch.
Gets mad at boyfriend when he comes over and eats her food.
Carcinosum remedy: 30C in water. After remedy, ate in front of parents at wedding, potassium has increased. “Started to
realize that I’m wasting food, it is ethically wrong”, realized that her boyfriend is a mirror of her. They have attracted each
other. Realized how much pain she has given her mother. Starting to increase awareness.

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