Eating Disorders New Threats to Health
DAVID
B.
HERZOG, M.D.
1feel honored by this opportunity to pay tribute to my former chief, Tom Hackett. I was indeedfortunate to know Tom. He was a major influence in my life. He knew ofmy interest ill eatin~ disorders alld was illstrumental ill helpin~ me start the Eatin~ Disorders Unit at Massachusetts Gelleral Hospital. The clinic was opelled in 1981. and in the 10 years hellce we have evaluated more thall 2,500 adolescent alld adult patients with eatillg disorders. At the outset Tom was 1I0t particularly interested ill eatin~ disorders, yet he was always willing to put time into my projects. He assisted me in developing a curriculum for a top-notch course Oil eatin~ disorders alld helped me obtain lIecessary fu"din~ for eatillg disorder research. Tom always encouraged me to embrace new challenges. 1 will be eternally grateful to him, alld 1 miss him.
T
he ideal model for treating hospitalized eating disorder patients centers on interdisciplinary collaboration. Many pediatricians. family practitioners. and internists consider eating disorders to be purely psychiatric disorders. They refer their eating disorder patients to a psychiatrist on admission and then distance themselves from active treatment for the remainder of the patients' hospitalization. In contrast. some clinicians collude with their patients in denying the psychological aspects of their disorders. even the disorder itself. and seek psychiatric consultation only at the end of the patients' hospitalization. if at all. These two extreme methods fail to address all crucial aspects of these disorders. A team approach in which all clinicians work together is necessary. Eating disorders are very complex and can-
Dr. Herzog is associate professor of psychiatry, Harvard Medical School. and director. Eating Disorders Unit. Massa· chusetts Gener.1I Hospital. Boston. MA. Copyright © 1992 The Academy of Psychosomatic Medicine. 10
not be treated as simple medical problems or purely psychiatric issues. A patient's treatment history may involve years of contact with numerous professionals including pediatricians. internists. gynecologists. family practitioners. and mental health professionals. who often act independently of each other. For example. a gynecologist may quickly prescribe birth control pills to an amenorrheic anorexic woman who is ambivalent. if not terrified. about the prospect of menstruating. A pediatrician or internist may unknowingly make a remark that scares or humiliates a patient. A psychotherapist must recognize that patients in therapy may fear that divulging information about their eating disorder behavior will result in the therapist's disgust or may even result in the therapist's termination of the relationship. If the clinician is not aware of the nuances of these disorders. the treatment may lead to a negative experience for the patients and may even be harmful to them. Clinicians must therefore be well informed about the diagnosis. signs. symptoms. and medical complications of eating disorders.· PSYCHOSOMATICS
Herzog
ANOREXIA NERVOSA: SIGNS AND SYMPTOMS The physical appearance of an anorexic woman has definite characteristics. Cachexia and breast atrophy are observable and the patient may look younger than her biological age. Her skin is often dry and may be yellow-tinged as a result of carotenemia. Cyanosis of the extremities is common, especially on exposure to cold temperature, as is lanugo, an increase in the fine hair on the body. The most common cardiovascular finding among anorexics is bradycardia; heartbeats as low as 25 beats per minute have been reported. However. there is no clear evidence that such a change predisposes a patient to malignant arrhythmias. Hypotension has been measured in up to 85% of hospitalized anorexic patients. Despite malnourishment, an anorexic woman is usually hyperactive and full of energy; lethargy is a worrisome finding because it is not usually present until the end stage of the illness and may reflect cardiovascular compromise. BULIMIA NERVOSA: SIGNS AND SYMPTOMS Unlike an anorexic woman whose emaciation is apparent, a bulimic patient can hide her problem more easily. Detection of surreptitious purging is a challenge to physicians who treat adolescents and young adults. These patients may complain of swelling of the hands and feet, abdominal fullness, fatigue, headaches, swelling of the cheeks, dental problems, chest pain, constipation, rectal bleeding, or fluid retention. Most bulimic women have few, if any, noticeable signs of the illness. However, there are three symptoms that are observable upon physical examination that can be used to aid in the diagnosis of bulimia nervosa. One is the evidence of skin changes over the dorsum of the hand, known as Russell's sign. These changes are thought to be secondary to the trauma to the skin caused by using the hand as an instrument to stimulate the gag reflex. A second symptom is hypertrophy of the salivary glands, particularly the parotid glands. The hypertrophy is usually bilateral, painless, and can be quite VOLUME 33· NUMBER 1 • WINTER 1992
apparent. I have consulted on two separate cases referred from the Massachusetts Eye and Ear Infirmary in which a patient was on the operating table awaiting surgery on her parotid glands before she acknowledged that she was bingeing and purging. Otolaryngologists should use caution when they consider operating on these patients. 2 A third symptom is the presence of perimolysis, or dental enamel erosion. Medical practitioners should be aware of this symptom of bulimia; otherwise it may not be detected until a routine dental examination. MEDICAL COMPLICATIONS OF ANOREXIA NERVOSA Electrocardiographic Abnormalities These abnormalities are common among low-weight patients and include low voltage, bradycardia, T wave inversions, and ST segment depression. The most worrisome findings are arrhythmias, including supra-ventricular premature beats. ventricular tachycardia with and without exercise, and ventricular tachycardia following emetine use. Prolonged Q-T intervals are rare but may predispose patients to life-threatening arrhythmias and explain some of the cases of sudden death. All of these changes should revert to normal after weight gain. Although cardiovascular complications are common, it is not possible to predict which patients will ultimately have life-threatening symptoms. Hematologic Changes Pancytopenia can result from starvation. Although neutrophils are decreased in many anorexics, it does not appear that an anorexic patient is more susceptible to infection on this basis. A normochromic or hypochromic anemia may be noted and is usually not due to a specific nutritional deficiency. The need for transfusion is very rare. Iron supplements may sometimes be necessary, but refeeding is the central treatment modality. II
Festschrift for Thomas P. Hackett
Gastrointestinal Complications Complaints of constipation and abdominal bloating may be the result of delayed gastric emptying and slowed intestinal motility. Metoclopromide has been used with some success to increase gastric motility. but it can lead to depression. Elevated serum amylase levels are often present in anorexic patients and usually reverse with weight gain. Liver enzymes may also be elevated. possibly due to fatty degeneration of the liver; these abnormalities also reverse with weight gain. Renal Abnormalities The most common renal abnormality is an increase in blood urea nitrogen, usually the result of dehydration. A decrease in renal concentrating capacity and abnormalities in vasopressin secretion may produce a partial diabetes insipidus and explain the polyuria that is a frequent complaint of anorexics. The insomnia often reported in this population may not be a symptom of depression but rather a result of polyuria. Renal calculi are common among anorexics due to chronic dehydration. Hydration and weight gain reverse all of these changes. although vasopressin secretion may not return to normal for some time after restoration of weight. Endocrine Abnormalities Amenorrhea is characteristic of anorexia nervosa. The relationship between weight loss and amenorrhea is not a simple one, however. Amenorrhea occurs in nearly one-third of anorexic women prior to severe weight loss, and the return of menses usually lags behind weight gain. In addition. some chronically underweight women menstruate regularly. Thyroid Abnormalities Anorexic women may demonstrate clinical features of mild hypothyroidism, including constipation, cold intolerance, bradycardia, dry skin, and increased relaxation time of deep tendon 12
reflexes. They do not have primary hypothyroidism, however. Thyroxine and thyrotropin levels are usually in the low-normal to normal range. Clinical signs of hypothyroidism probably reflect a relative deficiency of triiodothyronine. and these abnormalities return to normal upon weight gain. Skeletal Abnormalities Both adolescent and adult women with chronic anorexia nervosa may demonstrate decreased bone density representing osteoporosis that often leads to fractures of the vertebrae, sternum, and long bones; these complications of osteoporosis are usually seen only in post-menopausal women. In a follow-up study of a previously reported population,' Rigotti et al. 4 noted that even with return to normal body weight, low levels of bone density do not increase. We do not know whether these bone density levels will normalize over a longer period of time; if not, these women are at a much greater risk for fractures. Growth may be seriously impeded in children and adolescents who restrict their food intake, and their bone growth may be permanently impeded. Cholesterol and Carotene Cholesterol levels may be markedly increased in anorexic women. This is probably due not to intake of foods high in cholesterol or fats, but to disturbed lipoprotein metabolism. Carotene levels are elevated in many anorexics. These abnormalities reverse with weight gain. MEDICAL COM PLICAnONS OF BULIMIA NERVOSA Chronic Vomiting Self-induced vomiting is a common practice among bulimics and can result in fluid and electrolyte imbalance; hypokalemia. hyponatremia. and hypochloremic alkalosis are frequently observed. Emetine poisoning, which results from the use of ipecac to induce vomiting, may cause PSYCHOSOMATICS
Herzog
irreversible myocardial damage. Chronic vomiting may also lead to frequent complaints of sore throat, abdominal pain, esophagitis, and mild hematemesis. Laxative Abuse Laxative abuse is a common though rather ineffective and potentially dangerous form of purging. Weight loss is achieved through chronic dehydration because calorie absorption is not significantly reduced by laxative abuse. Laxatives cause electrolyte depletion, particularly of potassium bicarbonate, which leads to metabolic acidosis. Gastrointestinal Complications Elevated serum amylase levels are not uncommon and usually reverse with cessation of vomiting. Renal Abnormalities The most common renal abnormality is an increase in blood urea nitrogen, usually the result of dehydration. Renal calculi in bulimics are probably more common because ofchronic dehydration associated with vomiting and laxative abuse. Hydration will reverse these changes. Endocrine Abnormalities Although amenorrhea is more prevalent among anorexic women, in our clinic population of normal weight bulimic women, more than one-fourth had irregular menses or amenorrhea. 5 EVALUATION OF ANOREXIC AND BULIMIC PATIENTS Eating disorder patients should have an initial test battery that includes a complete blood count, liver function tests, and tests for levels of serum electrolytes, BUN, glucose, calcium, phosphorous, and magnesium. An electrocardiogram with rhythm strip is desirable for most patients. If the patient's history on physical examination sugVOLUME 33· NUMBER I • WINTER 1992
gests misuse of ipecac, a thorough cardiac assessment is suggested. Urine samples may be indicated to detect diuretic and laxative use. In the atypical anorexic, a complete neurological assessment is often indicated as well. A thorough psychiatric assessment is essential because comorbid disorders are extraordinarily common. These include depressive disorders, anxiety disorders, substance abuse disorders (particularly among bulimics), obsessive compulsive disorders, frequent Axis II pathology, and occasional psychosis. TREATMENT OF ANOREXIA NER VOSA The goal of medical treatment on patients' hospitalization is usually to achieve a safe weight for the patients and to rule out other possible causes of the weight loss and changes in vital signs or electrolytes. Clear guidelines concerning the weight goal during the period of hospitalization, discussed and agreed upon by all members of the treatment team, must be established early and communicated to the patients and their families. Patients must be told that they are malnourished and that starvation affects their thinking, which results in this need for medical intervention. Consumption of 3,000 or 3,500 calories a day may be necessary to achieve weight gain because of the patients' chronic state of malnutrition. However, to avoid potential stress on the patients' hearts and the risk of congestive heart failure, calorie intake should not be increased too rapidly. An anorexic woman is terrified of gaining weight. She should be warned of possible ankle edema and facial swelling that may result from refeeding to prepare her emotionally and to avoid losing the therapeutic alliance. The edema usually responds to salt and water restriction. Various medications have been used in the treatment of anorexia nervosa, most commonly antipsychotic drugs, antidepressants, and antihistamines. Studies to date suggest that thymoleptic medications generally do not show superiority over a placebo for the treatment of anorexia nervosa; however, psychotropic medication may be used as an adjunct to psychotherapy. Once the patient's weight is restored to a safe range, I 13
Festschrift for Thomas P. Hackett
would recommend using an antidepressant as the first choice for an anorexic woman with concomitant major depressive disorder. Additionally, a patient with more vegetative signs, marked preoccupations, or rituals may benefit from a tricyclic antidepressant or a monoamine oxidase inhibitor. Although antianxiety agents have not been well studied, they have been helpful to some of my patients to reduce mealtime food-related anxiety. The involvement of a skilled nutritionist is of great benefit throughout the course of treatment. The nutritionist should be tolerant of the slow pace of weight gain that anorexic patients require and can be resourceful in discovering small changes in eating behavior to fit patients' styles and idiosyncrasies. The psychiatric team that treats an anorexic patient should use behavioral treatment, supportive psychotherapy, and family therapy. Family therapy is often a vital aspect of the treatment plan, particularly with young patients living at home or with patients whose families present an obstacle to recovery. Involvement of the extended family in treatment (e.g., grandparents, siblings, boyfriends, spouses, and others who are important to the patient) may provide additional support to further progress. Other goals include organizing an outpatient treatment team and determining a safe place for the patient to thrive, either at home, at a halfway house, or at a residential treatment center. TREATMENT OF BULIMIA NERVOSA The primary goal of medical management for bulimic patients is to correct electrolyte abnormalities that arise from extensive bingeing and purging. Because this treatment can generally be done in an emergency room, bulimics rarely require hospitalization. Sometimes there is a need for a diagnostic hospitalization for a more comprehensive evaluation, but usually the normalweight bulimic who requires hospitalization will be admitted to a psychiatric ward. Pharmacotherapy is sometimes used as part of a treatment plan for bulimic women. A trial of antidepressant medication is often warranted re14
gardless of the absence of depression. Those patients who are resistant to antidepressants might try lithium as an adjunct to the antidepressant; the appetite suppressant, fenfluramine; or the opiate antagonist, naltrexone. Psychiatric treatment for bulimia should include cognitive-behavioral and interpersonal psychotherapy, on an individual or group basis, as well as the family therapy model described above. OUTCOME Outcome studies of anorexia nervosa show a greater rate of mortality the longer a patient has the disorder. At 5 years, the mortality rate is about 5%,6 whereas in a recent IO-year follow-up study/ the mortality rate was about 6.5%. In a 20-year follow-up study,H the mortality rate was 16%, and in a 33-year follow-up study,~ the mortality rate was 18%. Those deaths were secondary to anorexia nervosa and not due to other causes. However, studies show that most patients continue to recover even after 10-15 years of illness. There have not been many outcome studies of bulimia nervosa, and few have covered an extended period of time. Our work at Massachusetts General Hospital suggests that these patients recover slowly and have a high rate of relapse. 10 RESISTANCE TO TREATMENT Clinicians may find treatment of this population frustrating. Resistance to seeking or accepting treatment is a common feature of individuals with eating disorders. With regard to the anorexic, denial of the illness is inherent in the symptomatology of the disorder. How does one develop a therapeutic relationship with individuals who do not recognize the weight problem for which they are hospitalized?6 Anorexic women have an uncanny ability to fool those around them. I consulted on the case of a young college student at a university hospital who had an arrangement with her therapist to maintain her weight above 95 lbs to keep her car at school. Unbeknownst to her therapist, she would consume 6lbs of water within an hour or two of the weekly weighing. One PSYCHOSOMATICS
Herzog
day she miscalculated, became hyponatremic, seized, and aspirated. Fortunately, she survived. How does the psychiatrist meet both the requirements of medical safety and the goal of creating an alliance with a suspicious, reluctant patient? Much of psychiatric practice, like medical practice in general, depends upon the shared commitment of patient and physician to promote recovery. Forming a treatment alliance with an anorexic patient is often a slow and difficult task. It is gradually built through shared communication, perceptions, and emotions. Shame about the symptomatology is common for bulimics who have often hidden their symptoms from everyone in their lives. Their apprehension about revealing their secrets increases their resistance to treatment. For an integrated treatment program to succeed, parental resistance may have to be overcome as well. In the child and adolescent population, parental involvement is important to understand the child and to develop an alliance for treatment. Parents may resist psychiatric treatment fortheirchild for many reasons. includ-
ing the following: I) it is not the family style of problem solving, 2) they have had previous frustrating experiences with the mental health field, or 3) they fear that a family secret will be revealed. Such family secrets can include sexual or physical abuse, veiled parental separation, parental alcoholism, a psychotic relative, or other family illness. Even though there are often misgivings, the family must be encouraged to participate as an integral part of the evaluation process. Clinicians can treat eating disorder patients without having a specialty in this field. They do, however, need to be comfortable with these chronic complex disorders and with the substantial frustration they can generate in their caretakers. Eating disorder patients test our greatest skills as consultants and present us with our toughest dilemmas. The confident clinician can set the tone for the entire team by being well informed, tolerant, flexible. firm, and committed.
The author thanks Jocelyn R. Normand for her assistance in the preparation of this manuscript.
References I. Brotman AW. Rigoni NA. Herzog DB: Medical compli-
2. 3.
4.
5.
6.
cations of eating disorders. COn/PI' Psychiatry 26:25&272, 1985 Rauch SD. Herzog DB: Parotidectomy for bulimia: a dissenting view. Am 1 Otolaryngol 8:376-380. 1987 Rigoni NA. Nussbaum SR. Herzog DB. et al: Osteoporosis in women with anorexia nervosa. N Engl 1 Med 311:1601-1606.1984 Rigoni NA. Neer RM. Skates SJ. et al: The clinical course of osteoporosis in anorexia nervosa: a longitudinal study of conical bone mass. lAMA 265: 1133-1138. 1991 Copeland PM. Herzog DB: Menstrual disturbances in bulimia. in PsychabialoJlY afBulimia. Edited by Hudson J. Pope H. Washington. DC. American Psychiatric Association. 1987 Herzog DB. Keller MB. Lavori PW: Outcome in anorexia nervosa and bulimia nervosa: a review of the
VOLUME 33 • NUMBER I • WINTER 1992
literature. 1 Nerl' Melli Dis 176:131-143. 1988 7. Halmi K: The course and outcome of eating disorders. Presented at the Third International Conference of Eating Disorders. New York. April. 1988 8. Ratnasuriya RH, Eisler I. Szmukler GI. et al: Anorexia nervosa: outcome and prognostic factors after 20 years. Br 1 Psychiatry 158:495-502. 1991 9. Theander S: Research on outcome and prognosis of anorexia nervosa and some results from a Swedish longterm study. International loumal of Eating Disorders 2:167-174.1983 10. Keller MB. Lavori PW. Herzog DB. el al: High rates of chronicily and rapidity of relapse in patients with bulimia nervosa and depression. Arch Gen Psychiatry 46:480481. 1989 II. Hamburg P. Herzog DB. Brotman AW. et al: The treatment resistant eating disordered patient. Psychiatric Annals 19:49~99. 1989
15
DAVID
B.
HERZOG, M.D.
1feel honored by this opportunity to pay tribute to my former chief, Tom Hackett. I was indeedfortunate to know Tom. He was a major influence in my life. He knew ofmy interest ill eatin~ disorders alld was illstrumental ill helpin~ me start the Eatin~ Disorders Unit at Massachusetts Gelleral Hospital. The clinic was opelled in 1981. and in the 10 years hellce we have evaluated more thall 2,500 adolescent alld adult patients with eatillg disorders. At the outset Tom was 1I0t particularly interested ill eatin~ disorders, yet he was always willing to put time into my projects. He assisted me in developing a curriculum for a top-notch course Oil eatin~ disorders alld helped me obtain lIecessary fu"din~ for eatillg disorder research. Tom always encouraged me to embrace new challenges. 1 will be eternally grateful to him, alld 1 miss him.
T
he ideal model for treating hospitalized eating disorder patients centers on interdisciplinary collaboration. Many pediatricians. family practitioners. and internists consider eating disorders to be purely psychiatric disorders. They refer their eating disorder patients to a psychiatrist on admission and then distance themselves from active treatment for the remainder of the patients' hospitalization. In contrast. some clinicians collude with their patients in denying the psychological aspects of their disorders. even the disorder itself. and seek psychiatric consultation only at the end of the patients' hospitalization. if at all. These two extreme methods fail to address all crucial aspects of these disorders. A team approach in which all clinicians work together is necessary. Eating disorders are very complex and can-
Dr. Herzog is associate professor of psychiatry, Harvard Medical School. and director. Eating Disorders Unit. Massa· chusetts Gener.1I Hospital. Boston. MA. Copyright © 1992 The Academy of Psychosomatic Medicine. 10
not be treated as simple medical problems or purely psychiatric issues. A patient's treatment history may involve years of contact with numerous professionals including pediatricians. internists. gynecologists. family practitioners. and mental health professionals. who often act independently of each other. For example. a gynecologist may quickly prescribe birth control pills to an amenorrheic anorexic woman who is ambivalent. if not terrified. about the prospect of menstruating. A pediatrician or internist may unknowingly make a remark that scares or humiliates a patient. A psychotherapist must recognize that patients in therapy may fear that divulging information about their eating disorder behavior will result in the therapist's disgust or may even result in the therapist's termination of the relationship. If the clinician is not aware of the nuances of these disorders. the treatment may lead to a negative experience for the patients and may even be harmful to them. Clinicians must therefore be well informed about the diagnosis. signs. symptoms. and medical complications of eating disorders.· PSYCHOSOMATICS
Herzog
ANOREXIA NERVOSA: SIGNS AND SYMPTOMS The physical appearance of an anorexic woman has definite characteristics. Cachexia and breast atrophy are observable and the patient may look younger than her biological age. Her skin is often dry and may be yellow-tinged as a result of carotenemia. Cyanosis of the extremities is common, especially on exposure to cold temperature, as is lanugo, an increase in the fine hair on the body. The most common cardiovascular finding among anorexics is bradycardia; heartbeats as low as 25 beats per minute have been reported. However. there is no clear evidence that such a change predisposes a patient to malignant arrhythmias. Hypotension has been measured in up to 85% of hospitalized anorexic patients. Despite malnourishment, an anorexic woman is usually hyperactive and full of energy; lethargy is a worrisome finding because it is not usually present until the end stage of the illness and may reflect cardiovascular compromise. BULIMIA NERVOSA: SIGNS AND SYMPTOMS Unlike an anorexic woman whose emaciation is apparent, a bulimic patient can hide her problem more easily. Detection of surreptitious purging is a challenge to physicians who treat adolescents and young adults. These patients may complain of swelling of the hands and feet, abdominal fullness, fatigue, headaches, swelling of the cheeks, dental problems, chest pain, constipation, rectal bleeding, or fluid retention. Most bulimic women have few, if any, noticeable signs of the illness. However, there are three symptoms that are observable upon physical examination that can be used to aid in the diagnosis of bulimia nervosa. One is the evidence of skin changes over the dorsum of the hand, known as Russell's sign. These changes are thought to be secondary to the trauma to the skin caused by using the hand as an instrument to stimulate the gag reflex. A second symptom is hypertrophy of the salivary glands, particularly the parotid glands. The hypertrophy is usually bilateral, painless, and can be quite VOLUME 33· NUMBER 1 • WINTER 1992
apparent. I have consulted on two separate cases referred from the Massachusetts Eye and Ear Infirmary in which a patient was on the operating table awaiting surgery on her parotid glands before she acknowledged that she was bingeing and purging. Otolaryngologists should use caution when they consider operating on these patients. 2 A third symptom is the presence of perimolysis, or dental enamel erosion. Medical practitioners should be aware of this symptom of bulimia; otherwise it may not be detected until a routine dental examination. MEDICAL COMPLICATIONS OF ANOREXIA NERVOSA Electrocardiographic Abnormalities These abnormalities are common among low-weight patients and include low voltage, bradycardia, T wave inversions, and ST segment depression. The most worrisome findings are arrhythmias, including supra-ventricular premature beats. ventricular tachycardia with and without exercise, and ventricular tachycardia following emetine use. Prolonged Q-T intervals are rare but may predispose patients to life-threatening arrhythmias and explain some of the cases of sudden death. All of these changes should revert to normal after weight gain. Although cardiovascular complications are common, it is not possible to predict which patients will ultimately have life-threatening symptoms. Hematologic Changes Pancytopenia can result from starvation. Although neutrophils are decreased in many anorexics, it does not appear that an anorexic patient is more susceptible to infection on this basis. A normochromic or hypochromic anemia may be noted and is usually not due to a specific nutritional deficiency. The need for transfusion is very rare. Iron supplements may sometimes be necessary, but refeeding is the central treatment modality. II
Festschrift for Thomas P. Hackett
Gastrointestinal Complications Complaints of constipation and abdominal bloating may be the result of delayed gastric emptying and slowed intestinal motility. Metoclopromide has been used with some success to increase gastric motility. but it can lead to depression. Elevated serum amylase levels are often present in anorexic patients and usually reverse with weight gain. Liver enzymes may also be elevated. possibly due to fatty degeneration of the liver; these abnormalities also reverse with weight gain. Renal Abnormalities The most common renal abnormality is an increase in blood urea nitrogen, usually the result of dehydration. A decrease in renal concentrating capacity and abnormalities in vasopressin secretion may produce a partial diabetes insipidus and explain the polyuria that is a frequent complaint of anorexics. The insomnia often reported in this population may not be a symptom of depression but rather a result of polyuria. Renal calculi are common among anorexics due to chronic dehydration. Hydration and weight gain reverse all of these changes. although vasopressin secretion may not return to normal for some time after restoration of weight. Endocrine Abnormalities Amenorrhea is characteristic of anorexia nervosa. The relationship between weight loss and amenorrhea is not a simple one, however. Amenorrhea occurs in nearly one-third of anorexic women prior to severe weight loss, and the return of menses usually lags behind weight gain. In addition. some chronically underweight women menstruate regularly. Thyroid Abnormalities Anorexic women may demonstrate clinical features of mild hypothyroidism, including constipation, cold intolerance, bradycardia, dry skin, and increased relaxation time of deep tendon 12
reflexes. They do not have primary hypothyroidism, however. Thyroxine and thyrotropin levels are usually in the low-normal to normal range. Clinical signs of hypothyroidism probably reflect a relative deficiency of triiodothyronine. and these abnormalities return to normal upon weight gain. Skeletal Abnormalities Both adolescent and adult women with chronic anorexia nervosa may demonstrate decreased bone density representing osteoporosis that often leads to fractures of the vertebrae, sternum, and long bones; these complications of osteoporosis are usually seen only in post-menopausal women. In a follow-up study of a previously reported population,' Rigotti et al. 4 noted that even with return to normal body weight, low levels of bone density do not increase. We do not know whether these bone density levels will normalize over a longer period of time; if not, these women are at a much greater risk for fractures. Growth may be seriously impeded in children and adolescents who restrict their food intake, and their bone growth may be permanently impeded. Cholesterol and Carotene Cholesterol levels may be markedly increased in anorexic women. This is probably due not to intake of foods high in cholesterol or fats, but to disturbed lipoprotein metabolism. Carotene levels are elevated in many anorexics. These abnormalities reverse with weight gain. MEDICAL COM PLICAnONS OF BULIMIA NERVOSA Chronic Vomiting Self-induced vomiting is a common practice among bulimics and can result in fluid and electrolyte imbalance; hypokalemia. hyponatremia. and hypochloremic alkalosis are frequently observed. Emetine poisoning, which results from the use of ipecac to induce vomiting, may cause PSYCHOSOMATICS
Herzog
irreversible myocardial damage. Chronic vomiting may also lead to frequent complaints of sore throat, abdominal pain, esophagitis, and mild hematemesis. Laxative Abuse Laxative abuse is a common though rather ineffective and potentially dangerous form of purging. Weight loss is achieved through chronic dehydration because calorie absorption is not significantly reduced by laxative abuse. Laxatives cause electrolyte depletion, particularly of potassium bicarbonate, which leads to metabolic acidosis. Gastrointestinal Complications Elevated serum amylase levels are not uncommon and usually reverse with cessation of vomiting. Renal Abnormalities The most common renal abnormality is an increase in blood urea nitrogen, usually the result of dehydration. Renal calculi in bulimics are probably more common because ofchronic dehydration associated with vomiting and laxative abuse. Hydration will reverse these changes. Endocrine Abnormalities Although amenorrhea is more prevalent among anorexic women, in our clinic population of normal weight bulimic women, more than one-fourth had irregular menses or amenorrhea. 5 EVALUATION OF ANOREXIC AND BULIMIC PATIENTS Eating disorder patients should have an initial test battery that includes a complete blood count, liver function tests, and tests for levels of serum electrolytes, BUN, glucose, calcium, phosphorous, and magnesium. An electrocardiogram with rhythm strip is desirable for most patients. If the patient's history on physical examination sugVOLUME 33· NUMBER I • WINTER 1992
gests misuse of ipecac, a thorough cardiac assessment is suggested. Urine samples may be indicated to detect diuretic and laxative use. In the atypical anorexic, a complete neurological assessment is often indicated as well. A thorough psychiatric assessment is essential because comorbid disorders are extraordinarily common. These include depressive disorders, anxiety disorders, substance abuse disorders (particularly among bulimics), obsessive compulsive disorders, frequent Axis II pathology, and occasional psychosis. TREATMENT OF ANOREXIA NER VOSA The goal of medical treatment on patients' hospitalization is usually to achieve a safe weight for the patients and to rule out other possible causes of the weight loss and changes in vital signs or electrolytes. Clear guidelines concerning the weight goal during the period of hospitalization, discussed and agreed upon by all members of the treatment team, must be established early and communicated to the patients and their families. Patients must be told that they are malnourished and that starvation affects their thinking, which results in this need for medical intervention. Consumption of 3,000 or 3,500 calories a day may be necessary to achieve weight gain because of the patients' chronic state of malnutrition. However, to avoid potential stress on the patients' hearts and the risk of congestive heart failure, calorie intake should not be increased too rapidly. An anorexic woman is terrified of gaining weight. She should be warned of possible ankle edema and facial swelling that may result from refeeding to prepare her emotionally and to avoid losing the therapeutic alliance. The edema usually responds to salt and water restriction. Various medications have been used in the treatment of anorexia nervosa, most commonly antipsychotic drugs, antidepressants, and antihistamines. Studies to date suggest that thymoleptic medications generally do not show superiority over a placebo for the treatment of anorexia nervosa; however, psychotropic medication may be used as an adjunct to psychotherapy. Once the patient's weight is restored to a safe range, I 13
Festschrift for Thomas P. Hackett
would recommend using an antidepressant as the first choice for an anorexic woman with concomitant major depressive disorder. Additionally, a patient with more vegetative signs, marked preoccupations, or rituals may benefit from a tricyclic antidepressant or a monoamine oxidase inhibitor. Although antianxiety agents have not been well studied, they have been helpful to some of my patients to reduce mealtime food-related anxiety. The involvement of a skilled nutritionist is of great benefit throughout the course of treatment. The nutritionist should be tolerant of the slow pace of weight gain that anorexic patients require and can be resourceful in discovering small changes in eating behavior to fit patients' styles and idiosyncrasies. The psychiatric team that treats an anorexic patient should use behavioral treatment, supportive psychotherapy, and family therapy. Family therapy is often a vital aspect of the treatment plan, particularly with young patients living at home or with patients whose families present an obstacle to recovery. Involvement of the extended family in treatment (e.g., grandparents, siblings, boyfriends, spouses, and others who are important to the patient) may provide additional support to further progress. Other goals include organizing an outpatient treatment team and determining a safe place for the patient to thrive, either at home, at a halfway house, or at a residential treatment center. TREATMENT OF BULIMIA NERVOSA The primary goal of medical management for bulimic patients is to correct electrolyte abnormalities that arise from extensive bingeing and purging. Because this treatment can generally be done in an emergency room, bulimics rarely require hospitalization. Sometimes there is a need for a diagnostic hospitalization for a more comprehensive evaluation, but usually the normalweight bulimic who requires hospitalization will be admitted to a psychiatric ward. Pharmacotherapy is sometimes used as part of a treatment plan for bulimic women. A trial of antidepressant medication is often warranted re14
gardless of the absence of depression. Those patients who are resistant to antidepressants might try lithium as an adjunct to the antidepressant; the appetite suppressant, fenfluramine; or the opiate antagonist, naltrexone. Psychiatric treatment for bulimia should include cognitive-behavioral and interpersonal psychotherapy, on an individual or group basis, as well as the family therapy model described above. OUTCOME Outcome studies of anorexia nervosa show a greater rate of mortality the longer a patient has the disorder. At 5 years, the mortality rate is about 5%,6 whereas in a recent IO-year follow-up study/ the mortality rate was about 6.5%. In a 20-year follow-up study,H the mortality rate was 16%, and in a 33-year follow-up study,~ the mortality rate was 18%. Those deaths were secondary to anorexia nervosa and not due to other causes. However, studies show that most patients continue to recover even after 10-15 years of illness. There have not been many outcome studies of bulimia nervosa, and few have covered an extended period of time. Our work at Massachusetts General Hospital suggests that these patients recover slowly and have a high rate of relapse. 10 RESISTANCE TO TREATMENT Clinicians may find treatment of this population frustrating. Resistance to seeking or accepting treatment is a common feature of individuals with eating disorders. With regard to the anorexic, denial of the illness is inherent in the symptomatology of the disorder. How does one develop a therapeutic relationship with individuals who do not recognize the weight problem for which they are hospitalized?6 Anorexic women have an uncanny ability to fool those around them. I consulted on the case of a young college student at a university hospital who had an arrangement with her therapist to maintain her weight above 95 lbs to keep her car at school. Unbeknownst to her therapist, she would consume 6lbs of water within an hour or two of the weekly weighing. One PSYCHOSOMATICS
Herzog
day she miscalculated, became hyponatremic, seized, and aspirated. Fortunately, she survived. How does the psychiatrist meet both the requirements of medical safety and the goal of creating an alliance with a suspicious, reluctant patient? Much of psychiatric practice, like medical practice in general, depends upon the shared commitment of patient and physician to promote recovery. Forming a treatment alliance with an anorexic patient is often a slow and difficult task. It is gradually built through shared communication, perceptions, and emotions. Shame about the symptomatology is common for bulimics who have often hidden their symptoms from everyone in their lives. Their apprehension about revealing their secrets increases their resistance to treatment. For an integrated treatment program to succeed, parental resistance may have to be overcome as well. In the child and adolescent population, parental involvement is important to understand the child and to develop an alliance for treatment. Parents may resist psychiatric treatment fortheirchild for many reasons. includ-
ing the following: I) it is not the family style of problem solving, 2) they have had previous frustrating experiences with the mental health field, or 3) they fear that a family secret will be revealed. Such family secrets can include sexual or physical abuse, veiled parental separation, parental alcoholism, a psychotic relative, or other family illness. Even though there are often misgivings, the family must be encouraged to participate as an integral part of the evaluation process. Clinicians can treat eating disorder patients without having a specialty in this field. They do, however, need to be comfortable with these chronic complex disorders and with the substantial frustration they can generate in their caretakers. Eating disorder patients test our greatest skills as consultants and present us with our toughest dilemmas. The confident clinician can set the tone for the entire team by being well informed, tolerant, flexible. firm, and committed.
The author thanks Jocelyn R. Normand for her assistance in the preparation of this manuscript.
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cations of eating disorders. COn/PI' Psychiatry 26:25&272, 1985 Rauch SD. Herzog DB: Parotidectomy for bulimia: a dissenting view. Am 1 Otolaryngol 8:376-380. 1987 Rigoni NA. Nussbaum SR. Herzog DB. et al: Osteoporosis in women with anorexia nervosa. N Engl 1 Med 311:1601-1606.1984 Rigoni NA. Neer RM. Skates SJ. et al: The clinical course of osteoporosis in anorexia nervosa: a longitudinal study of conical bone mass. lAMA 265: 1133-1138. 1991 Copeland PM. Herzog DB: Menstrual disturbances in bulimia. in PsychabialoJlY afBulimia. Edited by Hudson J. Pope H. Washington. DC. American Psychiatric Association. 1987 Herzog DB. Keller MB. Lavori PW: Outcome in anorexia nervosa and bulimia nervosa: a review of the
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literature. 1 Nerl' Melli Dis 176:131-143. 1988 7. Halmi K: The course and outcome of eating disorders. Presented at the Third International Conference of Eating Disorders. New York. April. 1988 8. Ratnasuriya RH, Eisler I. Szmukler GI. et al: Anorexia nervosa: outcome and prognostic factors after 20 years. Br 1 Psychiatry 158:495-502. 1991 9. Theander S: Research on outcome and prognosis of anorexia nervosa and some results from a Swedish longterm study. International loumal of Eating Disorders 2:167-174.1983 10. Keller MB. Lavori PW. Herzog DB. el al: High rates of chronicily and rapidity of relapse in patients with bulimia nervosa and depression. Arch Gen Psychiatry 46:480481. 1989 II. Hamburg P. Herzog DB. Brotman AW. et al: The treatment resistant eating disordered patient. Psychiatric Annals 19:49~99. 1989
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