Pain II: Acid Reflux in Recovery

Pain is a rather unwanted and close companion as you travel through the maze towards remission from an eating disorder.

A member of the Eating Disorder Institute community recently posted on the forums that she has had an active eating disorder for several decades and recently is navigating a steady recovery process that has, not surprisingly, involved a significant level of gastrointestinal distress. Her doctor has diagnosed her with gastritis (an inflammation of the stomach lining that can have several possible causes) and prescribed a proton-pump inhibitor (PPI) drug to try to alleviate the symptoms. His anticipation is that the gastritis will resolve of its own accord. He has also decided not to requisition any tests or further screening at this time.

The community member felt that his decision to diagnose in the absence of further investigative testing reflects a trend she finds frustrating—that her medical advisers presume all her physical ailments are readily attributable to the progressive impact of restriction on her body. She likened the experience as equivalent to a smoker who sees a doctor with a cough and it’s automatically attributed to the smoking. Here are my observations on her circumstance as many navigate this exact same problem in recovery:

The doctor is right in some senses.

If a smoker goes to the doctor with a cough, then a reasonable intervention would be to require him to stop smoking first to rule out the most likely cause of the cough. You don't go looking for the least likely cause of the cough right out of the shoot. That's not just an expensive route to go, it also greatly increases the chance of iatrogenic harm (harm caused directly by medical tests and intervention).

However, if a smoking patient is then honest with his doctor and indicates a) “I have no intention of quitting smoking,” and b) “I would like to alleviate the symptom of this cough in whatever way I can short of quitting smoking,” then he is asking his doctor to help him reduce the harm of smoking and address symptoms within that context. Now obviously there are a lot of cultural attitudes that mean a doctor might refuse to treat a patient who continues to smoke and yet requests medical attention and care. I personally don’t support doctors that fire non-compliant patients.  Firing a patient is a moral, and not medical, judgment assigned to people’s lifestyles that inevitably results in a slippery slope of who/why you treat one person over another. However, even the smoker can likely find a doctor who will be willing to treat symptoms—one who understands that things we culturally believe are behaviors within our control may not always be behaviors that can be changed.

For those with long-term intractable eating disorders, the anxiety surrounding the impact of an eating disorder tends to reinforce a desire to avoid thinking about its impact on health. In other words, it's easier to be worried that the symptoms are not attributable to the eating disorder rather than to consider the possibility that the eating disorder is really to blame.

We see similar responses in those with phobias that limit quality of life. There’s a lot of cognitive gymnastics that goes along with trying to avoid even discussing the phobia itself, let alone how much it’s really responsible for a reduced quality of life. The reason for this is that just thinking about the phobia triggers the threat response system in the brain and the subsequent drive to fight/flee/freeze.

However for the community member in question, she is specifically navigating a tough re-feeding process and has made the decision to address the eating disorder directly. And that means she is not looking to say to her doctor: “I have an eating disorder. I need help to reduce the harm that this condition brings to my life.”

Within the context of pursuing remission while addressing gastritis, here is one possible way to resolve the current dissatisfactory situation the community member faces. She could follow up with her doctor with something similar to what follows:

“I am working on addressing the eating disorder. I am re-feeding. I am resting. Not surprisingly, there are symptoms I have now that are likely directly attributable to the damage that has occurred from years of restriction. I need you to help me with whatever you think might work to ease these symptoms as much as possible because they are brutal and are actually impeding my ability to keep working my way forward towards remission from the eating disorder. The PPI you prescribed unfortunately had too many side effects for me to manage. I have no issue with the diagnosis of gastritis, as it is a common symptom in recovery, however I also note that my compromised health status from years of restriction might mean it would be helpful to screen for Helicobacter pylori. And while the prevalence of H. pylori in patients with eating disorders is no greater than the population as a whole, its presence does impact gastric hormones and weight restoration. 1, 2, 3 Would you be willing to requisition a breath test for the presence of H. pylori just so we can rule it in or out? Could we also consider an H2 blocker* or perhaps another PPI to see if I might tolerate something else?”

Lots of “let's rule out everything” tests are expensive. Doctors get a lot of push from patients directly to screen for everything because we have a medical industrial complex that has figured out marketing these things directly to anxious patients generates far more income than relying on doctors to determine what screening might actually have the right level of risk-to-benefit outcome. By focusing your requests for targeted medical support in a way that speaks to a doctor’s sense of what’s likely or feasible, it may help you to get the symptom alleviation you need right now.

The next installment will look at the complexity of pain treatment for both the patient and her doctor.

* H2 blocker: this class of drug blocks the action of histamine 2 receptors on parietal cells in the stomach resulting in a reduction of the production of acid.

1. Sherman, Philip, Karen Leslie, Eudice Golderg, Jamie MacMillan, Richard Hunt, and Peter Ernst. "Helicobacter pylori infection in adolescents with eating disorders and dyspeptic symptoms." The Journal of pediatrics 122, no. 5 (1993): 824-826.

2. Osawa, Hiroyuki. "Ghrelin and Helicobacter pylori infection." World journal of gastroenterology: WJG 14, no. 41 (2008): 6327.

3. Hill, Kelly K., Daniell B. Hill, Laurie L. Humphries, Michael J. Maloney, and Craig J. McClain. "A role for Helicobacter pylori in the gastrointestinal complaints of eating disorder patients?." International Journal of Eating Disorders 25, no. 1 (1999): 109-112.