Each patient, and each patient's family, is unique. Each individual brings strengths, skills, and experiences to tackling the problems of life, including a biologically based illness like an eating disorder.
When an eating disorder is diagnosed, the clinical team will also be looking for other factors which may impact the illness and recovery. When two illnesses are present at the same time, it is called "co-morbidity" or "dual diagnosis." Some of these conditions are worsened by the symptoms of the eating disorder, some make recovery more difficult, some put the patient at risk of relapse. But there is good news as well: successful diagnosis and treatment of co-morbid illnesses can offer benefits in treating the eating disorder and quality of life after recovery.
One of the most common conditions found along with an eating disorder is anxiety. Anxiety disorders, in fact, are often found in families and relatives of eating disorder patients. Most patients who go on to develop anorexia, in particular, have a history of anxiety and "obsessionality."
Anxiety does not always look like the classic stereotype of a nervous person. Anxiety often looks to others like irritability, anger, shyness, or rigidity. A young person who finds benign issues unbearable, or a child who avoids situations for what seem to be irrational reasons, for example, may be suffering from crippling anxiety.
Obsessionality is also often misunderstood. People are often admired for the same traits that with examination are discovered to be things the person "has to" do rather than "wants to" do. A very diligent student who won't stop studying even when peers are exhausted is an example. Or the athlete who "lives for" her sport and works harder than all her teammates, even to the point of injury.
Since anxiety disorders often become apparent during puberty, the same time eating disorders usually begin, it can be hard to discover which came first. Young people are often unable to articulate the strong anxiety they are feeling, and the rapid changes of that developmental phase confound clear delineation between conditions.
The behaviors of an eating disorder are often experienced by young people as anxiety relievers; restricting, binging, and purging feel BETTER than the intolerable level of anxiety they feel every day. For those with this predisposition, restricting calories reduces physiological sensations of anxiety. This means even low levels of malnutrition can keep a person in a state of lowered anxiety just at a time when they normally would be learning skills of emotional regulation and tolerating distress. Binging and purging also provide physiological effects which blunt or temporarily reduce anxiety for certain people.
Recovery from an eating disorder often requires treatment for underlying anxiety issues. For some this will mean psychotherapy (usually Cognitive Behavioral Therapy or Dialectical Behavioral Therapy) to learn techniques and skills to cope with stress and anxiety and avoid use of eating disorder behaviors. Some patients have underlying anxiety disorders that will need treatment through psychotherapy or drugs.
Another common co-morbid condition is depression. Like anxiety, it can be hard to discover what came first - the eating disorder or the depression. And also as in the case of anxiety it can be difficult to know whether the symptoms are being caused by restriction, by withdrawal from the eating disorder behaviors, or an underlying condition. Another common factor: depression doesn't always look like sadness or a Hollywood depiction of this very serious and common mental disorder. Depression can look like anger, apathy, resentment, chronic disappointment in others or society, or social withdrawal.
Depressive symptoms are an expected natural consequence of early malnutrition. This may mean that nutritional recovery alone will bring relief, but rarely immediately. Parents should be aware, however, that the symptoms of depression can temporarily worsen as the body is restored, and it is common for it to take many months for the brain to recover. This period of time is very difficult for the patient and requires careful monitoring and support from family.
Suicide is the leading cause of death in eating disorders. Parents must keep this fact in mind and be prepared to provide around the clock presence and support as needed. Skilled clinicians should be involved, and all suicidal talk or behaviors taken extremely seriously.
We are all familiar with modern society's focus on appearance and particularly on thinness. But some people suffer actual brain changes which cause "dysmorphia." The person is not exaggerating or over-valuing a physical aspect: the person literally sees the distortion on the body and in the mirror. Eating disorders, by altering brain chemistry, can cause body dysmorphia or make it far worse - often the distortion exaggerates body size or proportions. In some cases, the body dysmorphia is resolved as the patient regains nutritional and medical health.
The standard treatment for pre-existing or continuing BDD is SSRI drugs, which is successful in many cases.
Cutting and self-injury
Although it is commonly mistaken for a suicidal impulse, "cutting" is believed by experts to be a self-medicating response to extreme anxiety. It is often found in patients who have had or go on to develop eating disorders, especially bulimia. As a sign of extreme distress, and an indication of a person unable to tolerate their level of anxiety, it should be taken as an indication of extreme feelings. It is never appropriate to get angry or punitive with a person who is compelled to do these behaviors. Parents must take this behavior seriously, seek expert advice, and make sure that treatment for self-injury is coordinated with the eating disorder treatment.
Some people have, in addition to an eating disorder, what is called a Personality Disorder. These disorders make relationships difficult.These disorders are treatable, but are thought of as lifelong conditions that can be managed, not cured. A personality disorder can make eating disorder recovery particularly difficult.
It is very important to provide full family history and a developmental history of your loved one in order to help with a full diagnosis. Many parents find the questions clinicians have to ask very intrusive, even insulting. Since personality disorders are associated with childhood abuse, parents may be rightly indignant to be questioned about these issues. Keep in mind that clinicians must ask these questions and get a full view of your child's history in order to rule out other difficulties. It is prudent, with this very serious and sometimes misunderstood diagnosis, to seek second opinions if a personality disorder is diagnosed. It is also important to keep in mind that many of the symptoms of an eating disorder resemble those of personality disorders, and have a reassessment after full recovery has been achieved and maintained.
Stress, whether from internal or external origins, complicates eating disorder symptoms and all efforts to recover. It also hampers caregivers in having the energy and resources to provide a safe environment. If your family leads a high-stress lifestyle, or the eating disorder patient's personality has created a schedule which distracts from recovery, many families find that treating eating disorder recovery as one would a grave injury is helpful. Cutting back on expectations and obligations, and letting go of any external calendar deadlines can be beneficial to the whole family. Stress is an emotional and physiological drain, and deserves to be treated seriously during initial recovery and preventing relapse.
There are many medical conditions that can complicate or even be mistaken for an eating disorder. Diabetes, thyroid issues, autoimmune disorders, gallstones, achalasia, vitamin deficiencies, Lyme disease, and strep infections are all important for you and your clinical team to assess and treat with the eating disorder in mind.