In my previous article on the relationship between Osteopenia or Osteoporosis and Anorexia, I mentioned that high-cortisol levels can also cause bone loss. What does it mean to have high cortisol levels? 

Cortisol is a hormone that goes up when we get upset. In my experience, Anorexia is a disorder characterized by extreme anxiety which means that cortisol levels are chronically high, making the bone loss a more likely result of the eating disorder.

This is certainly a new twist on an old theme. Most people are very much aware of the fact that nutritional deficiencies among those suffering from Anorexia result in bone loss (as well as tooth decay.) But very few people seem to be aware that anxiety may play such a crucial role in driving bone loss as well. When I say very few people, I include practitioners. 

The reason I am focusing on this particular aspect of Anorexia is that I think unless Anorexia is viewed as an anxiety disorder, and treated accordingly, treatment will fail. Not only will we miss the opportunity to prevent more bone loss, we also miss the opportunity to be as effective as possible when it comes to treating this very serious eating disorder. 

Conventional treatment is failing those individuals with Anorexia when you consider that less than 50% of those receiving treatment recover. We must also take into consideration that those suffering from Anorexia have the highest mortality rate of any other emotional disorder.

What I have seen over the years is that the patient is deemed to have “recovered” if s/he has agreed to consume enough calories to maintain a medically stable weight. But such individuals are often more at risk of relapse for starters, and also still continue to have bone loss, often progressing from Osteopenia to Osteoporosis in their “recovered” state. In addition, it isn’t unusual for such individuals to lose most if not all of their teeth.

I tell parents all the time that the patient is the least anxious, and therefore has the lowest cortisol levels, when s/he is restricting. Of course the restricting causes the parents to be extremely anxious. Conversely when the patient begins to re-feed the parent relaxes a bit but the patient’s anxiety increases significantly. This is especially true in conventional treatment where the pressure to gain weight quickly is so intense. 

It isn’t unusual for a residential treatment program to insist that the patient gain 20 pounds in 20 days as that is the length of time that insurance covers treatment. A normal person would have difficulty gaining that much weight in that short of a time period, let alone someone suffering from Anorexia.

The issue of bone loss in this population and its connection to cortisol levels isn’t a well documented finding because most practitioners are not testing for Osteopenia or Osteoporosis in their Anorexic patients. If they were, it might be possible to prevent the Osteopenia, which is reversible, from progressing to Osteoporosis, which is not reversible. 

In my practice I do insist that my patients get tested. Not surprisingly, the rate is very high with as much as 40% of my patients who suffer from Anorexia having at least Osteopenia if not Osteoporosis. 

So why is this happening? Part of the problem is that the conventional approach to Anorexia pushes for significant weight gain in a relatively short period of time as mentioned above. This approach drives anxiety levels that are already unbearable for the Anorexic patient threw the roof. Such individuals need more time to acclimate to both eating as well as gaining weight. Instead of treatment taking three months, treatment should be seen as a 12 to 24 month process that begins with intensive treatment and decreases in frequency as the patient’s anxiety comes under control. In other words we treat this as an anxiety disorder rather than simply an eating disorder.

So what do I mean when I say treating the Anorexia as an anxiety disorder?

The difference between treating Anorexia as an anxiety disorder and treating it as an eating disorder only is that more time is spent identifying and treating the sources of the anxiety. In other words, in addition to re-feeding and meal planning, treatment is also focused upon relieving said anxiety. Such treatment might include emotional freedom tapping (EMT,) dialectical behavioral therapy (DBT,) Eye Movement Desensitization and Reprogramming (EMDR) and Family Therapy. 

Regarding the latter, many eating disorders are a function of an unhealthy or dysfunctional family dynamic. Even the most loving parents can struggle when it comes to parenting their child, especially if that child is Anorexic. This may be why the only treatment that has ever been shown to be effective when it comes to treating Anorexia is a family systems approach. I am, and will always be, a family systems therapist. I usually do not work with a patient unless I am also working with his or her parents or partner for this reason. It works. 

When you consider how often conventional treatment excludes family members altogether and all but ignores the issue of anxiety, it is understandable that these patients have such low recovery rates along with such high death rates. Yes, I said death rates. The highest death rate for any emotional disorder is among those suffering from Anorexia. 

While I have never had a patient die, I can understand why the death rate among those suffering from Anorexia is so high. It goes back to the level of anxiety again. It is unbearable. Over time, if the focus continues to be on refeeding instead of on reducing the anxiety, and the causes of that anxiety continue to be at issue, the patient simply gives up.

Bottom line: a family systems-based approach that recognizes the crucial role of anxiety in treating this disorder will be far more successful.

In the last article of this series, I will discuss specific supplements and strategies for strengthening bones so stay tuned.