Author:  Center for Change

The following indicators are significant and common signs and symptoms of anorexia and bulimia. Critical or multiple indicators suggest the need for medical, dietary and psychological intervention. The items marked by an asterisk (*) may indicate an urgent need for intervention and treatment.

PHYSIOLOGICAL AND MEDICAL INDICATORS

  • Below 85% of normal body weight range , or BMI below 16%
  • * Below 70% of normal body weight, or BMI below 14
  • Unexplained weight loss, especially in adolescents
  • *Electrolyte disturbances such as: serum potassium below 2.6 mmol/L or above 6 mmol/L; repeated drops in potassium below 3.0; serum calcium below 6 mg/dL or above 13 mg/ dL
  • *EKG abnormalities indicating electrolyte disturbance.
  • Bone marrow suppression indicated by neutropenia and anemia
  • Bradycardia below 60
  • Serum protein or albumin above or below normal
  • Low T4, elevated TSH, and/or low LH
  • *Palpitations
  • *Syncope or near-syncope
  • Dizziness or light-headedness
  • Amenorrhea (absence of menstruation for more than 3 months) or highly irregular menstruation
  • Dehydration or repeated need for rehydration in previous 12 months
  • Chest pain
  • Hypothermia or report of cold intolerance
  • Hair loss or breakage
  • Lanugo hair on face, neck, back, and arms
  • Yellowish tinge to skin, purplish-blue hands and feet.
  • Hypercarotenemia
  • Orthostatic blood pressure and pulse changes
  • Dental problems including enamel erosion
  • *Esophageal tear / blood in vomit
  • Swollen or tender parotid glands
  • Frequent gastroesophageal reflux into throat / mouth
  • Chronic indigestion / heartburn
  • Severe constipation
  • Extreme and chronic fatigue / weakness
  • Brittle bones
  • Non-focal abdominal pain with consumption of food
  • Abdominal bloating / swelling of hands, ankles, and feet
  • Elevated serum amylase or lipase
  • Elevated liver enzymes
  • *Persistent diarrhea, (may be bloody)
  • *Pancreatitis
  • *Severe abdominal pain (may indicate impending visceral rupture)

DIETARY INDICATORS

  • Caloric intake reported by the patient is under 800 kcal / day
  • *Inability or refusal to keep any food down
  • Engaging in food games (i.e., hiding food, hoarding food, chewing and spitting food out, cutting food into tiny pieces, lying about what food has been eaten, etc.)
  • Eating the same foods every day / rigid food rituals
  • Limiting food to only vegetables and fruit / eliminating fats and proteins
  • *Refusing to drink water or consuming less than 8 oz / day, or restricting water intake for 2-7 days
  • Binging two or more times daily on excessive quantities of food
  • Purging two or more times daily
  • Inability to maintain weight
  • *Rapid weight loss; losing more than two pounds weekly
  • Unable or unwilling to stop or decrease compulsive exercise, exercising more than two hours daily, or having extreme feelings of guilt, inadequacy, or anxiety if unable to exercise
  • Spending more than 75% of waking hours thinking about food, calories, fat, body, and weight
  • Unable to follow a food plan without excessive food involvement or excessive food avoidance
  • Unable to follow a food plan provided by a dietitian without restricting or “bargaining” with the eating disorder
  • Laxative abuse
  • Abusing over-the-counter diet pills or diet aids, or excessive drinking of caffeinated drinks
  • *Inability to withdraw from laxatives, diet pills, or diuretics

COGNITIVE, EMOTIONAL, BEHAVIORAL, RELATIONAL INDICATORS

  • Self-injury such as cutting, scratching, burning
  • *Failure of outpatient treatment
  • Failure to respond to psychiatric medications
  • *Slowness in thought, inability or severe difficulty in making decisions, difficulty in tracking conversation, etc.
  • Poor concentration: inability to focus
  • Poor memory — inability to recall conversations or interactions after one day
  • Poor functioning academically or at work
  • Feeling of pride in excessive weight loss or in the ability to deny self of food or to resist hunger
  • Significant absence at school or work
  • Intense feelings of shame and self-disgust in relation to eating habits
  • Significant body distortion with associated emotional distress and anxiety
  • Intense feelings of weakness, guilt, or inadequacy over eating food
  • After eating, subsequent restriction or selfpunishment to compensate for caloric intake
  • Minimizes or gets angry and defensive at loved ones’ expressed concerns about eating habits
  • Inability or unwillingness to eat in front of others
  • Expresses intense and unreasonable fear of gaining weight or “becoming fat”
  • *Suicidal ideation that is worsening, or the eating disorder is becoming the means for suicide
  • *Suicidal gestures or attempts
  • Other complex, concurrent psychological disorders and/or symptoms (i.e. depression, anxiety, panic disorder, obsessive compulsive disorder, personality disorders, etc.)
  • Long and chronic history of eating disorder (over 5 years)
  • *Short and intense history of eating disorder with severe and rapid deterioration
  • Obsessive comparing of body size or shape to other women
  • Avoiding others or “pushing away” family / friends
  • Constant lying, deception, and secrecy to hide eating disorder
  • Concurrent and alternating addictions (e.g., stealing, exercise, sexual activity, drugs, alcohol, cutting)
  • *Extreme emotional detachment, disengagement and numbness
  • Significant isolation or withdrawal
  • Extreme emotional despair and feelings of hopelessness
  • Trauma related symptoms that require safety and containment
  • Extreme feelings of self-contempt and selfhatred
  • Extreme obsessive thought patterns and/or perfectionism
  • *Deterioration despite outpatient medical, dietary, and psychological care

MEDICAL TREATMENT GUIDELINES

Involve a team of professionals including a psychologist or therapist, dietitian, psychiatrist, and medical physician. Communicate regularly with the team.

  • Baseline initial medical evaluation:
    • Medical history
    • Physical examination
    • CBC
    • EKG
    • Creatinine
    • TSH
    • Amylase
    • Urinalysis
    • DEXA scan
  • Frequent medical monitoring may be necessary until clear improvement is evident.
  • Consider the use of SSRIs or other psychiatric medication, particularly if depression or obsessive-compulsive behaviors are present. Consult a psychiatrist as needed.
  • Assess and address any suicidal thoughts or risk.
  • Medical stabilization, re-nourishment and weight restoration are a high priority.

RESOURCES

Medical

Mehler PS, Anderson S, eds. Eating Disorders: A Guide to Medical Care and Complications: Baltimore, John Hopkins University Press, 1999.

Dietary

Reiff DW, and Reiff K, Eating Disorders: Nutrition Therapy in the Recovery Process, Life Enterprises Publisher 1999.

Psychological

Garner DM, Garfinkel PE, eds. Handbook of Treatment for Eating Disorders, 2nd edition, New York: Guilford, 1997.

ACKNOWLEDGEMENT

Elizabeth Blackwell, MD, for her assistance in the compilation and review of the 2001 version of this guide.

Center for Change in Orem, Utah, offers a comprehensive continuum of care for women suffering from anorexia and bulimia. The Center has a 16-bed inpatient treatment program and offers a variety of outpatient services including assessments, dietary counseling, and therapy.

Please feel free to contact Center for Change for additional information about our programs or to arrange an appointment for an eating disorder evaluation. Contact information is listed below.

© Center for Change, Incorporated, April 2000
Revised: November, 2009