Complications of Anorexia Nervosa: Why medical evaluation and monitoring is critical

Andrew Hopkins, PA-C

In life, food is our friend and starvation is our enemy.

The human body is very effective in energy conversion. It breaks down food into the necessary nutrients our cells needs to function. Without food, the body transitions into starvation. As the body starves, it begins to break itself down and converts fat and protein into energy. This is a temporary strategy for the body if you miss lunch or are unable to eat for a few hours. But what if your body can’t count on food? What if your body is being permanently starved?

Missing a meal v. Anorexia nervosa

Individuals with Anorexia intentionally restrict food intake leading to starvation, weight-loss, and a low body weight. There is a fear of weight-gain or a fear of “becoming fat”, despite being profoundly underweight. Individuals with anorexia also demonstrate a distorted perception of body weight and image, and may often deny the medical seriousness of a low body weight.

Starvation is deadly.

The rate of death in Anorexia is a staggering 10-12 times higher than the general population.1,2,3 In addition, the rate of suicide in Anorexia is nearly 5 times higher than the general population.4,5,6 Medical complications, including heart attacks and heart failure, account for more than half of all deaths in patients with Anorexia. The two biggest risk factors leading to medical complications include the degree of weight loss and how long food restriction has been present for.

Fats, proteins, and changes within the body

In starvation, the body begins to break itself down to create cellular energy in a process known as catabolism. In Anorexia, where there is long-term starvation, the body turns to a more substantial supply of fat and protein: the vital organs. The body breaks down proteins and fats in the heart, brain, liver, kidneys, and muscle leading to atrophy, or tissue wasting. Atrophy results in poorly functioning organ systems and ultimately, organ failure.

Symptoms and signs

While considerable changes to the body and organs are occuring, symptoms may be vague, misleading, or non-existent. Fatigue, low motivation, and changes in mood are common in the course of Anorexia. More concerning signs may be objectively measured, such as low blood pressure, reduced heart rate and reduced core body temperature. Some organ failure can occur without any warning signs or symptoms. Many patients who experience medical complications due to Anorexia require hospitalization due to severity. This makes medical evaluation and screening critical immediately following the diagnosis of Anorexia.   

Comprehensive evaluation and medical monitoring

Immediately following the diagnosis of Anorexia nervosa, one should have a comprehensive medical evaluation. This should include an extensive physical exam to evaluate for any objective manifestations of weight-loss and low body weight. Blood work is critical to identify for any nutrient deficiencies, abnormal hormone levels, or early signs internal organ failure. An Electrocardiogram (EKG) is needed to evaluate heart health and rule-out any functional changes related to heart atrophy. In females who have not menstruated for over 9 months, it is common to have a Bone Density Study (or DEXA scan) performed to rule-out early-onset Osteoporosis. Any abnormalities during this initial medical evaluation may require hospitalization to stabilize and correct.

Reversing Complications and Restoring Health

The treatment of Anorexia always involves weight restoration. While medical complications may necessitate urgent medical care, nearly all medical complications of Anorexia nervosa can be effectively reversed with adequate weight-gain. However, weight is not the only marker of recovery. It is appropriate to perform continual medical screenings throughout treatment. In order to vigilantly monitor for medical complications during recovery, frequent screenings involving blood work, vital signs, and a review of systems are routinely incorporated.



What’s next?

Treatment of Anorexia often involves a team of providers. At Potomac Behavioral Solutions, our treatment team will work collaboratively to ensure to the best outcomes. We offer dietitian services, family-based therapy (FBT), and medical monitoring during treatment to improve outcomes. Please contact our intake coordinators for further information on how to get started with our treatment team today!


Work Cited:

  1. Löwe B, Zipfel S, Buchholz C, Dupont Y, Reas DL, Herzog W. Long-term outcome of anorexia nervosa in a prospective 21-year follow-up study. Psychol Med. 2001;31(5):881-90.

  2. Keel PK, Dorer DJ, Eddy KT, Franko D, Charatan DL, Herzog DB. Predictors of mortality in eating disorders. Arch Gen Psychiatry. 2003;60(2):179-83.

  3. Herzog W, Deter HC, Fiehn W, Petzold E. Medical findings and predictors of long-term physical outcome in anorexia nervosa: a prospective, 12-year follow-up study. Psychol Med. 1997;27(2):269-79.

  4. Hoang U, Goldacre M, James A. Mortality following hospital discharge with a diagnosis of eating disorder: national record linkage study, England, 2001-2009. Int J Eat Disord. 2014;47(5):507-15.

  5. Suokas JT, Suvisaari JM, Gissler M, et al. Mortality in eating disorders: a follow-up study of adult eating disorder patients treated in tertiary care, 1995-2010. Psychiatry Res. 2013;210(3):1101-6.

  6. Crow SJ, Peterson CB, Swanson SA, et al. Increased mortality in bulimia nervosa and other eating disorders. Am J Psychiatry. 2009;166(12):1342-6.



Dieting: Much More Harm Than Good

Julia Yuskavage, MS, RDN

I think most people can agree that the last few months of 2018 have been filled with weight loss television commercials, radio ads for diet programs, and coupons for herbal products that promise a quick fix for “losing that stubborn body fat”. There is a reason for all of this - the dieting industry continues to profit big time from selling these kinds of products. Many times, people believe that if they were able to lose weight or fit into a smaller clothing size, then they might feel happier about themselves and their lives. However, I wonder how much truth there is in this belief.

What many people don’t know, or don’t want to believe, is that the companies that bombard you with these advertisements have a common goal: to sell you something.

Some of the questionable ideas hidden in these messages might sound like…

  • Lose those last 10 pounds and you will be happier!

  • Stop eating carbs and people will notice you!

  • Reduce your belly fat and your dating life will improve!

  • Give up “bad” foods and you will feel better about yourself!

  • Drop 3 dress sizes and you will have finally accomplished something worthwhile!

In fact, a leader of a weight loss corporation has been quoted as saying that their product is great for business because people who use it will inevitably fail, thus returning for more of it (i.e.: buying it) again and again and again. That makes me feel frustrated for people who are using these systems and working hard to meet their nutritional goals/needs.

The reality is that there is no magical number on the scale or measuring tape that will make you feel whole. What diets often lead to are vicious cycles of food restriction, low energy levels, moodiness, overeating, and feelings of guilt, shame, and failure – that then leads to food restriction all over again.

“If you just tried hard enough and did a better job at dieting, you wouldn’t be a failure” is the message that the diet industry is trying to sell. It’s no wonder that the temptation is so high to try a different diet approach each time you feel like a “failure”. Diets often do not lead to long-term health and happiness; instead, they often lead to disordered eating and even early mortality associated with eating disorders.

We’re here to remind you that it’s okay to love yourself JUST the way you are. Accepting yourself and working through the underlying emotions that fuel your desire to diet and lose weight can be a path to freedom.

So often we see clients who are torn between wanting to end dieting once and for all, yet also wanting to lose weight because they believe doing so will lead to happiness. It can be tough to feel like you are stuck between wanting to follow a non-diet approach, yet also wanting to lose weight. If one is willing, there can be a sense of freedom that comes with giving up self-imposed dietary rules, learning to listen to your body’s hunger and fullness cues (or eating intuitively), and accepting yourself for the unique individual that you are. Intuitive eating is referenced as a “dynamic process – integrating attunement of mind, body, and food”(1). The great news is that you have the skills to eat intuitively inside you already – you were born with them; they just got pushed way down, buried under all the societal pressures and norms that have tried for so long to convince you otherwise. If this is how you are feeling/what you are noticing, it might be time to work on letting that skill resurface and start walking the path towards healing your relationship with food and your body. If you would like to learn more about intuitive eating, or if you have concerns about your current eating habits, we are here to help.



  1. Tribole E, Resch E. Intuitive Eating. A Revolutionary Program That Works; 2012:1-344.



Sarah Fischer, PhD in the News!

Dr. Fischer has been interviewed by several media sources related to her most recent research at George Mason University and Potomac Behavioral Solutions! Thank you to all the participants who volunteered. 

 Sarah Fischer, PhD

Sarah Fischer, PhD


Monday, July 10, 2017
Contact: Jim Sliwa

(202) 336-5707


Scans suggest food is a form of escape from self-critical thoughts

WASHINGTON -- Magnetic resonance imaging scans suggest that the brains of women with bulimia nervosa react differently to images of food after stressful events than the brains of women without bulimia, according to research published by the American Psychological Association.

In women with bulimia, the researchers found decreased blood flow in a part of the brain associated with self-reflection, compared with increased blood flow in women without bulimia. This suggests that bulimics may be using food to avoid negative thoughts about themselves, the researchers said. 

“To our knowledge, the current study is the first investigation of the neural reactions to food cues following a stressful event in women with bulimia nervosa,” said lead author Brittany Collins, PhD, of the National Medical Center. The research was published in the Journal of Abnormal Psychology.

Stress is considered to be a trigger for binge-eating in patients with bulimia nervosa, but there is little research on how people with bulimia nervosa process and respond to food cues.
The researchers conducted two experiments. In the first, 10 women with bulimia and 10 without came to a lab where they all ate the same meal. After waiting for about an hour and becoming familiar with an MRI scanner, they then entered the scanner and were shown a series of neutral pictures, such as leaves or furniture, followed by a series of high fat/high sugar food pictures, such as ice cream, brownies, pizza or pasta with cheese sauce. 

Participants were then asked to complete an impossible math problem, a task designed to induce stress and threaten their ego. They then re-entered the scanner and looked at different photos of high fat/high sugar foods. After every activity in the scanner, the women rated their levels of stress and food cravings. 

“We found that everyone experienced increased stress after the stress task, and that everyone reported that stress went down after seeing the food cues again. Also, every time that participants saw the food cues, they reported that their craving for food went up,” said co-author Sarah Fischer, PhD, of George Mason University.

What was surprising was even though patterns of self-reported results were similar for both groups, the two groups showed very different brain responses on their MRI scans, Fischer said. For women with bulimia, blood flow to a region called the precuneus decreased. For women without the eating disorder, blood flow to this region increased. The precuneus is involved in thinking about the self.

“We would expect to see increased blood flow in this region when someone is engaged in self-reflection, rumination or self-criticism,” said Fischer.

In the second experiment, the researchers asked 17 women with bulimia nervosa to complete the same task as the women in the first study, in order to examine whether the findings could be replicated in a different sample of women.
“Our results were the same in the second study,” said Fischer. “Women reported increases in stress following the stress task and increases in food craving after seeing food cues. More important, blood flow to the same region, the precuneus, decreased when viewing food cues following stress.”

Collins believes that this decreased blood flow in bulimics suggests that the introduction of food shuts down self-critical thinking in bulimics and gives them something to focus on instead of the painful prospect of dealing with their own shortcomings.

Psychologists have previously theorized that binge-eating provides bulimic women an alternate focus to negative thoughts about themselves that may be brought on by stress. This research provides support for this theory, according to Collins.

“Our findings are consistent with the characterization of binge-eating as an escape from self-awareness and support the emotion regulation theories that suggest that women with bulimia shift away from self-awareness because of negative thoughts regarding performance or social comparisons and shift focus to a more concrete stimulus, such as food,” said Collins.

The results of these experiments could also suggest a neurobiological basis for the use of food as a distractor during periods of stress in women with the disorder, she said. The researchers called for further studies to confirm their results, which they termed preliminary.

The article is part of a special section of the July 2017 issue of the journal devoted to outstanding contributions by young investigators in the field of eating disorders.

“This issue is dedicated to highlighting the accomplishments of an impressive group of young researchers,” wrote the section co-editors Pamela Keel, PhD, Florida State University, and Gregory Smith, PhD, University of Kentucky, in their introduction. “The papers offer a glimpse into the many and multifaceted forms of progress young researchers are making in the effort to understand and address an extraordinarily important form of psychopathology, dysfunction related to the basic need of food consumption.”

    Article:  “The Impact of Acute Stress on the Neural Processing of Food Cues in Bulimia Nervosa: Replication in Two Samples,” by Brittany Collins, PhD, National Medical Center; Jennifer McDowell, PhD, and L. Stephen Miller, PhD, University of Georgia; and Lauren Breithaupt, MA, James Thompson, PhD, and Sarah Fischer, PhD, George Mason University. Journal of Abnormal Psychology, published July 10, 2017.

    Full text of the article is available from the APA Public Affairs Office and at

    Contact: Sarah Fischer can be contacted by email at or by phone at (703) 993-5635


    The American Psychological Association, in Washington, D.C., is the largest scientific and professional organization representing psychology in the United States. APA's membership includes nearly 115,700 researchers, educators, clinicians, consultants and students. Through its divisions in 54 subfields of psychology and affiliations with 60 state, territorial and Canadian provincial associations, APA works to advance the creation, communication and application of psychological knowledge to benefit society and improve people's lives.

    If you do not want to receive APA news releases, please let us know at or 202-336-5700.



    Binge Eating Disorder- The cycle that continues to feed itself


    Binge Eating Disorder- The cycle that continues to feed itself

    By: Annyck Besso, MS, RD

    “I woke up the next morning, in distress, telling myself that I needed to have more control over my eating and then everything would be ok.”  This sentence or a similar one may sound familiar to several individuals. In a society that places a great deal of importance on weight loss and healthy eating, most people believe that the problem is related to their “lack of control," rather than something greater. 

    What is Binge Eating Disorder?: 
    Binge Eating Disorder (BED) was first recognized as an eating disorder in the DSM V, which was published in 2013 (APA, 2017). The diagnostic criteria for BED include, but are not limited to, the perception of loss of control while eating a larger quantity of foods than considered “normal” in a specific period of time in addition to extreme feelings of guilt and shame afterwards.  While diagnostic criteria for BED does not include compensation following a binge (e.g., vomiting, laxative use).

     Figure 1- Common nutritional and emotional pattern that arises in many patients with BED

    Figure 1- Common nutritional and emotional pattern that arises in many patients with BED

    Restriction and the Binge Cycle:
    People with BED often report that they try to make up for the behavior the following day through restrictive eating. This restrictive eating behavior can present itself in several forms, such as using food rules to eat “healthier,” avoiding certain foods or limiting oneself to a certain amount of calories. Sometimes just the idea that tomorrow will be different can keep the binge cycle going. 

    The goal of your dietitian is to target restrictive eating, which normally perpetuates the cycle of feeling overly hungry then bingeing. Messages from social media often seem to condition us to believe that we can control what our bodies want and what they should look like. This battle can have dire consequences on our physical health, our mood and our emotional well-being.

    Sandra’s Story

    One example is a client who I will name Sandra. Sandra has always had a very difficult relationship with her body,  creating  food rules to try to control her weight and shape. For years, she attempted several diets, which worked initially, but then she ended up heavier and more demoralized after each one. She became confused as she was following her food rules and eating “healthy,”but was unable to lose any weight. Often, Sandra would come home from a long day of work and describe “zoning out” and eating whatever “forbidden foods” she could find over a period of an hour. When she would finally “snap out of it,” she was filled with feelings of guilt, shame and loathing for herself. She would reassure herself by saying that this was the last time and that she was going to get things under control the following day; she would get rid of all the junk food in her house and start anew. 

    While this may seem like a good strategy, this is exactly what I would NOT recommend a client to do. Food rules typically perpetuate the cycle of loss of control(led?) eating. It is not a lack of control that leads to bingeing; it is instead primarily the emotional relationship people have with food and their body (amongst other reasons). 

    Treatment Goals:
    Stopping the cycle: after a binge, do not try to “get back on track”. 
    Reconnecting with your body: try asking yourself how hungry you feel before a meal and how satisfied you feel after a meal. Try to let your body guide your food choices, rather than deciding what it should be having. 

    Accepting all foods: there is no such thing as a good food or bad food. All foods are good and serve different purposes in our lives. Eliminating a food or food group simply makes it novel and more interesting which leads us to become preoccupied with the food. 

    Eliminating mindless eating: if you eat at your desk, in front of the TV or in the car, this one is for you. Take time to just EAT and taste the food you’re putting in your mouth. It will feel much more satisfying. 

    Please note the strategies above are NOT as simple as they may seem. If you can identify with this article or know someone who has an emotional relationship with food, it may be beneficial for them or for you to talk with a Registered Dietitian. Please don’t hesitate to reach out.  
    American Psychiatric Association. (2017). DSM History. Retrieved from on June 19th, 2017. 

    Binge Eating Disorder Association. (2016). Characteristics of BED. Retrieved from on June 19th, 2017. 



    Body Image Acceptance!


    Annyck Besso, RD and Joanna Marino, PhD recently volunteered at a local kindergarten to provide education on body image acceptance and loving our bodies!




    The Downside of Missed Periods

      Sam Tryon, MS, RD

    Sam Tryon, MS, RD


    For some, the idea of not having their period might be cause for celebration.  No cramps, bloating or having to worry about keeping tampons or pads on hand; awesome right?! Unfortunately, not getting your period could be cause for concern.*

    If you are 16 years old and have not yet started your period or if you have missed at least 3, you could be diagnosed with amenorrhea.1 Amenorrhea can be caused by a variety of factors including genetic abnormalities, gland problems, and certain gynecological conditions.1  Amenorrhea may also be due to what you eat and how active you are.

    The roles of nutrition and activity

    Low energy availability is one cause of amenorrhea.  Energy availability is a measure of the energy left for bodily functions (i.e. heart beating, digestion, breathing) after subtracting for energy used during exercise and other activities of daily living (i.e. vacuuming, walking to work, gardening).  Low energy availability means that there is not enough energy for body functions and exercise.

    Low energy availability can be a result of not taking in enough fuel (A.K.A. not eating enough) and/or using too much energy for exercise.  Among other effects, the lack of energy left for bodily functions leads to decreased production of gonadotropin-releasing hormone, a hormone important in reproduction, which causes decreased production of estrogen and progesterone and disruption of the menstrual cycle.2

    Amenorrhea and Bone Health

    Both low energy availability and reproductive hormone changes have negative impacts on bone density.  In addition to not having the available energy and nutrients to maintain bone mass, lack of estrogen is associated with bone loss.  In a healthy body, our bones are constantly being broken down to release minerals like calcium and then rebuilt.  Without estrogen, there is increased breakdown without rebuilding which leads to decreased bone density.  This can progress to osteopenia and osteoporosis, putting a person at risk for fractures.  

    Studies have found that up to 95% of people with Anorexia Nervosa have osteopenia and as many as 40% have the more severe osteoporosis.3 Weight gain is associated with return of menstruation and possible reversal of at least some bone loss.

    Amenorrhea and bone loss are especially concerning in adolescents as peak bone mass is reached during this time. Bone loss from low energy availability during this stage of life may prevent patients from reaching a normal peak bone mass. This can put them at increased risk for fractures later in life.

    Next Steps

    If you have missed 3 or more periods, an appointment with your general physician can help to determine the cause of amenorrhea.  They may recommend a bone density test to look for possible bone loss.  

    If the cause is found to be nutrition related, a dietitian can help you change your diet to make sure you are taking in enough energy to fuel your body. Amenorrhea can occur with or without disordered eating and a dietitian can also help assess for any disordered eating behaviors.  If disordered eating is a problem, a therapist may be added to the team to best tackle these concerns and get you back to the activities you love.  

    *The content of this article is for informational purposes only and does not constitute medical advice, professional diagnosis, or treatment.  See your healthcare provider before making any healthcare decisions or with any questions you have regarding a medical condition.  


    1. Amenorrhea. Eunice Kennedy Shriver National Institute for Child Health and Human Development; [accessed 2017 May 31].

    2. Mallinson, R and De Souza, M. Current perspectives on the etiology and manifestation of the “silent” component of the Female Athlete Triad. Int J Womens Health. 2014; 6: 451–467

    3. Mehler, P and MacKenzie, T. Treatment of Osteopenia and Osteoporosis in Anorexia Nervosa: A Systematic Review of the Literature. Int J Eat Disord. 2009; 42: 195-201



    My Loved One has Borderline Personality Disorder -- What now?

    Borderline Personality Disorder is Treatable

    If you have a loved one who experiences symptoms of borderline personality disorder (BPD), you can learn more about how to help.   The National Education Alliance
    for Borderline Personality Disorder
     offers resources to family and friends such as:

    • Up-to-date research articles
    • Family Connections Program 
    • Free Webinars and Videos
    • Call-in series to learn more about BPD

    Join our Friends and Family skill class which is held from 6-7pm Tuesday evenings. The group costs $25 and is open to the public! You will learn more about BPD and Dialectical Behavior Therapy (DBT) 


    OCD Recovery

    Join Joanna Marino, PhD on June 2nd to learn more about OCD treatment success! 


    NEDA Walk, Washington, DC: April 2, 2017

     Alexa, Charlie (with Daria!), Joanna, and Rebecca 

    Alexa, Charlie (with Daria!), Joanna, and Rebecca 

     Alexa, Charlie (with Daria!), Joanna, and Rebecca

    Alexa, Charlie (with Daria!), Joanna, and Rebecca

     Evelyn and Alexa- Our WONDERFUL intake staff! 

    Evelyn and Alexa- Our WONDERFUL intake staff! 

     Rebecca and Alexa

    Rebecca and Alexa

     Evelyn and Joanna

    Evelyn and Joanna

     Joanna Marino, PhD giving a keynote speech at the DC NEDA walk!

    Joanna Marino, PhD giving a keynote speech at the DC NEDA walk!

     Alexa ;)

    Alexa ;)

     Our booth at the walk

    Our booth at the walk

     Joanna Marino, PhD giving a keynote speech at the NEDA walk

    Joanna Marino, PhD giving a keynote speech at the NEDA walk



    Social Anxiety Treatment

    Our Social Anxiety Program is starting March 13th, 2017. Please give us a call for more information. Skills class meets Monday from 5-630pm. 



    12 Week Program


    What is Comprehensive CBT (CCBT) for Social Anxiety?

    Our 12- week CCBT for Social Anxiety Program includes both individual and skills class (group) formats. The treatment incorporates several strategies in the following contexts:

    • Exposure through Role Plays
    • Cognitive Restructuring Exercises (e.g., identify and evaluate beliefs)
    • Social Skills Training  through Modeling and Coaching


    1. Skills Classes (Group)

    Classes include 6-10 participants and focus on skill acquisition and application in a supportive environment with real-time feedback. Classes are co-led by two therapists. Class is Monday from 5:00-6:30 pm. Sessions 1-2 are an introduction to CBT and social anxiety, sessions 3-4 are devoted to skills training (e.g., initiating, maintaining, and ending conversations, as well as compromise and negotiation), and sessions 5-12 involve exposure simulation, cognitive and behavioral skills acquisition, identification of cognitions, and generalization of skills to multiple contexts.

    2. Individual Therapy

    Patients meet with their individual therapists for several weeks of pre-treatment (before skills class begins) to develop goals, create a hierarchy of fears, and gain preliminary insight into their symptoms. Patients may also inquire about medication options during pre-treatment.

    3. Homework

    Homework is a required and essential part of CCBT for Social Anxiety in order to generalize skills to a variety of contexts. Participants in the program should expect daily homework that will be of increasing "intensity" to help challenge and overcome feared situations. Patients will also complete thought-logs which allow for the evaluation of inaccurate beliefs and development of alternative beliefs.