Eating disorders are among the most lethal conditions in psychiatry and some of the most misunderstood. In this episode, I’m joined by Dr. Patricia Westmoreland and Dr. Anne O’Melia, two internationally recognized experts with eight combined board certifications spanning psychiatry, internal medicine, pediatrics, and consultation-liaison psychiatry. Together, we take a deep dive into the medical, psychiatric, ethical, and forensic complexities of eating disorders, especially as they appear in the general medical hospital. We talk through how to recognize eating disorders in patients who may not even identify as ill, when to intervene, and what the thresholds for medical stabilization really look like. We also explore the psychological underpinnings, how control, trauma, and insight all intersect, and the delicate balance between autonomy and safety when capacity is limited.

Takeaways:

Eating disorders are both psychiatric and medical emergencies. Anorexia nervosa has one of the highest mortality rates of any psychiatric illness, surpassed only by opioid use disorder.
Early recognition saves lives. Common signs include unexplained bradycardia, electrolyte disturbances, fatigue, hypoglycemia, or rapid weight loss, even in patients who deny an eating disorder.
Patients often lack insight. Many individuals with severe anorexia are highly intelligent but unable to apply their knowledge to themselves, leading to deceptive presentations of “capacity.”
Treatment is multidisciplinary and stepwise. Levels of care range from outpatient and intensive outpatient programs to residential, psychiatric inpatient, and medical stabilization units, depending on weight, vitals, and lab findings.
Recovery is possible and expected. Full restoration of nutrition and function can reverse nearly every medical complication of starvation, and with the right care, patients can go on to live full, independent lives.

Key References:

1. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Eating Disorders (Crone 2023)

2. Ethical Challenges in the Treatment of Patients With Severe Anorexia Nervosa (Westmoreland 2024)

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