Gah! But, but, but.....

Having trouble letting this go on the drugs vs. food issue.

It's the anosognosia thing. Also: because I didn't state the question clearly enough.

Forget the study in question for a moment?  Here's the choice:

You have an eating disorder patient who isn't weight normalized and there is no plan to do so. The patient comes to a doctor but says I won't eat enough, but I want help. Does the doctor prescribe a drug that will help soften the effects of one medical problem - a critical one - knowing the patient will not be getting renourished at the same time?

I think a lot of people are responding to this as a question of lesser harm. I'm looking at it as the illness holding the doctor hostage: give me one form of poison or I'll take the other.If the doctor has a patient in care I think the doctor should be focusing on getting them the treatment they need and not being a tool of ED.

To argue that the patient "isn't ready" or "refuses" or "is still in pre-contemplation" is to misunderstand the illness. It is US who are "not ready" to deal with the messy and harrowing business of seeing the person in front of us as unABLE and not unWILLING to gain weight. The anosognosia of the illness changes the issue: the patient is unable, due to the effects of the "drug" of malnourishment, to see the situation clearly. The "drug" of real nourishment is the best known one for treating anosognosia - a far more dangerous side-effect than bone loss.


  1. i didn't read the other comments, but this is how i understood the question the first time you posted it.

    Maybe having had an eating disorder myself and having been in treatment before, I have a different perspective from you Laura, but I really think that the reality of this situtation needs to be faced:
    If this doctor were to be in this situation, it would be VERY DIFFICULT, hell, probably impossible, for him to get this person into treatment. The most likely situation, if this person was "refusing" treatment, is that this person has been anorexic for a long time, and then yes, is deeply entrenched in the ED and damaged by the malnourishment. What is the doctor supposed to do if they RECOMMEND treatment, give the patient a number of a therapist, dietitian, etc, ask him/her to PLEASE consider XYZ type of treament, to ask for help from family & friends, and the patient still denies this help?
    The only way I have heard of that this doctor could get this person into treatment is through a court order. And even that is messy.
    You cannot force an adult, anorexic or not, to go into treatment. This situation can often be helped if said adult has family and friends around who encourage him/her or just flat out refuse to deal with the person otherwise, or physically DRAG the person into treament (ive seen this).
    The fact of the matter is, by the time someone has been anorexic for this long, someone may not HAVE people in their life who are willing to do this. This is sad. Yes. But it is a possible reality.
    I agree with you that this person is deluded by the drug of malnourishment. But until something is fundamentally & LEGALLY changed in this country about an Eating Disorderd adults' right to refuse treatment, I honestly think that the pathetic and only option would be for the doctor to prescribe the medication. Not that i think this medication will really do anything to combat the effects of severe malnutrition, that's like taking potassium tablets while purging all the time- not gonna cut it.

  2. I find this question impossible to answer, even when phrased differently.

    Ideally, Laura, I agree with you that the doctor should do something and not colludge with the ed and that the patient should be refed and therapised back to full recovery.

    However, this is real life. In the real ed world, some people could suffer and refuse treatment for 20 years and then recover. If, during that 20 years, there was a way to help them stave off osteoporosis, as a doctor, wouldn't you do that? Just because someone is deeply entrenched in ed does not mean they should be written off, if there is some kind of treatment that can help their bones to recover.

    There is someone who knows what I am talking about. Would she have taken the drugs, knowing what she knows now that she is recovered?

    Until we can sort out this mess that is treatment for adult eating disorder sufferers all over the world, I still think this is a good and viable option so that, when they recover, they don't have to suffer as much with the crippling pain of their bones crumbling.

  3. I frequently use medication in my patients, but let's be clear:

    Without weight gain, you will get nothing.

  4. Julie

    I would never argue against weight gain!

    What I am trying to say (and very badly) is that we should not deny long-term sufferers a treatment that will help them once they recover.

    I don't believe in "chronic" and my dream is that every anorexia sufferer will receive the food and other treatment they need to make them better.

    However, until then, why shouldn't they receive this treatment? Surely prevention is better than cure?



  5. Having met the person I think Charlotte is talking about I agree - anything to keep this dear person as safe as possible during her struggle would surely better than alowing her to suffer still further from something that is possibly preventable (I agree, the drugs probably won't work very effectively during malnourishment).

    Rose is also right - the law just doesn't allow doctors (or parents, or anyone else) to force treatment on adult individuals unless it is an absolute matter of life and death and even then it is very hard to make someone go into treatment and almost impossible to keep them there against their will once the immediate threat has been dealt with.

    It might be the case that a doctor could advise the patient that he or she would not use a drug treatment unless the patient also engaged in the really necessary process of gaining weight, but surely that would be both cruel and useless. People with AN aren't stupid, intellectually they know that their behaviours are bad for them, it's just that the illness prevents them from being able to change them - adding one more option to feel guilty about won't change anything will it?

  6. When a person has AN, the idea of eating more and/or gaining weight is the scariest/hardest thing in the world. If I could have taken a concoction of pills to prevent the physical side effects of AN I would have done at the time - in order that I wouldn't have had to cope with the terrible anxiety that accompanied my recovery from AN.

    Without wanting to sound 'clever', I collected data for, and wrote up my PhD while anorexic - and I can tell you all that writing up a PhD was far, far easier than was changing my anorexic behaviours and gaining weight.

    If there was a drug that worked as effectively as food for the physical consequences of AN then I would recommend it - both for its effects and for ethical reasons. However, there simply isn't such a drug. The physical consequences of low weight AN are caused by adaptation/maladaptation starvation, so food and weight gain is the cure.

    I had a number of fractures due to osteoporosis, including a fractured pelvic. I tried the oral contaceptive pill, HRT, bisphosponates and even sodium fluoride, and these drugs had a minimal effect on my bone mass. Now that I understand the mechanism of bone loss in AN I can see why these powerful drugs with their unpleasant side effects lacked efficacy. As far as I can predict, the capacity to rebuild osteoporotic bone with DHEA while underweight and starved is limited. And, as I said previously, the physical damage caused by AN is widespread; it affects every cell, every tissue, every organ, every organ system.

    Chronic underweight leads to a shortened life with high morbidity. The data are available and are convincing. I totally agree that recovery from chronic AN is extremely difficult, and I have previously debated on this blog about the ethics and practicalities of forcing someone with chronic AN to gain weight when weight gain (or the process of achieving weight gain) are accompanied by sufficient panic to drive some peple to take their own lives. But there is no real pharmacological alternative when compared to food.

  7. I wouldn't argue against weight gain either, that is obviously going to be the best and most effective way to improve the bones-the problem is from not eating and the solution is eating. HOWEVER, if we look at the person's lifespan as a whole, and assume that they will get better someday, do we want them to have life long consequences for this if it's not necessary? And should we punish them with fractures because they weren't in treatment when we know that's a feature of their illness???

  8. There is no scientific evidence that the combo of DHEA and HRT would increase bone mineral density in the bones of someone who has anorexia nervosa and is not engaged in refeeding. As I mentioned in Laura's previous post, since no new amounts of food would be coming in, then IF bone density were increased, it would have to be at the expense of some other bodily system. If I were a doctor I would be very hesitant to prescribe a treatment that I didn't know would have even a chance of helping, and that might even hurt the sufferer more.

  9. How would you feel about denying a cholesterol- or blood pressure- or blood sugar-lowering drug to an obese individual because he or she has not seriously attempted to lose weight? It seems clear that in most situations, these conditions (high cholesterol, high blood pressure, early diabetes) can be ameliorated by dietary changes.

  10. OK, now THIS is a really great question! This makes me think!

    Here's the difference: the dietary changes in anorexia are also the necessary medicine to treat the self-perpetuating thoughts and behaviors that keep the illness and the bone loss and other medical effects in place.

    It is possible that this is true for illnesses that cause obesity - but I don't think that's your assumption here.

    But letting someone remain underweight with anorexia is GIVING the very drug that keeps the patient unwell - and knowing that the patient is anosognosic/unaware makes the difference.

  11. Laura, the presence of the anosognosic thinking in anorexia is an important and significant one. But I think that there remains the fact that a person who takes medications to reduce cholesterol and blood pressure and blood sugar but does not change his or her eating habits remains at very real risk for other effects of obesity, most notably stress on the joints (aka, arthritis). How about someone who is an alcoholic who develops liver problems? Persons with alcohol addictions are notorious for not acknowledging that they have problems. Treat or don't treat? Now, I don't know what my opinion is, e.g., give the drugs, don't give the drugs. I just think that, as you have acknowledged, it's a complicated and contentious issue.

  12. Can I just point out that it isn't always about the weight either. I know many adults (and I'm one of them) that have gained back the weight, and stopped eating again but due to years of starvation suffer from a severely damaged metabolim. Many of us don't eat, but stay within a low but normal weight range but are often just as sick (if not more, because of chronicity.) This is beside the point, but I want to scream every time I read it's about weight gain because so many of live off a severely restricted caloric intake but don't lose weight. It's NOT just about the weight. Anyone here would gasp if they knew my intake, but you wouldn't know by looking at me (unless they were looking at my blood under a microscope!) I'm thin, but not emaciated, as many adult women are. The focus of this blog is not adult women, but I'd love to see the words change from low weight to low nutrition. There is a huge difference. There a lot of very sick anorexics walking around at low but not anorexic weights, or even normal weights - but still restricting heavily. It's about so much more than weight.

  13. You don't always get a choice. It comes down to the sufferer. If the sufferer WILL NOT undergo any form of active recovery, yet has severe osteoporosis... it is feasible that the complications of osteoporosis will kill this person before any other physical effect of malnutrition. The goal is to prolong life. Ultimately to prolong "Active" life.

    An example I will give that I am making up right now to make a point is this: Take a person who has AN-caused osteoporosis and, because of that degradation of bone, will likely die within one year and do nothing but attempt refeeding, etc. They struggle the AN-sufferer's struggle and, at the end of the year, gain headway. They are well on their way to recovery! And they die because their bones caused them too much damage.. or, more gently, they are wheelchair bound for the rest of the foreseeable future because of horrible breaks in their bones which their body is not strong enough to heal correctly. Or, while continuously encouraging this person to get treatment and monitoring this person (even if that is limited to requiring hour-long check-ups before refilling the prescription) this drug is given and a year goes by. They are still alive, not wheel chair bound, and not undergoing treatment. YET. The more time you can give a person on this earth, the more time they have to find the will, the love, or the desperation to get help and live. And, having had this drug, even if it does not work as well as refeeding, their recovery may not be too late to save them from the deadly consequences of this particular disease.

    I understand where you are coming from, how this is a worrisome option. But it is also important to keep in mind that, though I have not specifically mentioned any here, there are various reasons why a person suffering AN may not be able to gain weight/refeed. One amazing person I used to speak with online had specific complications of Anorexia and Bulimia that are considered rare and required that much of her intestines be removed... There was a really hard struggle that ensued because at that point, right before this inevitable surgery option was explained to her, she decided she wanted to recover no matter what it took. She was unable to gain weight. She could not eat naturally, obviously, though there were various mechanical/medical variations that were meant to allow her to recieve nutrients, but her body rejected these solutions.

    I am not saying that this has much to do with osteoporosis. Her death was not caused by lack of bone density, etc. But she is not the only sufferer of an eating disorder to have complications that cause her body to not be able to absorb the appropriate nutrients. And I feel it is safe to say that some amount of this particular demographic may be in that situation (can't gain/refeed naturally) but still able to feel the effects of osteoporosis or potentially be able to somehow elongate their lives if they did receive treatment for this bone condition.


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