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 self-punishment 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 idealization 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 self-hatred
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.
c Center for Change, Incorporated, April 2000
Revised: November, 2009
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