Perspective The Role of the Primary Care Physician in the Diagnosis and Management of Anorexia Nervosa J. SILBER, M.D., M.A.S.S. LAWRENCE J. D'ANGELO, M.D., M.P.H. TOMAS
ThiS article discusses the appropriate role of the nonpsychiatric primary physician in the initial management and ongoing care of patients afflicted with anorexia nervosa. It is based on the experiences of both individual practitioners and members of a multidisciplinary eating disorders program that has been in existence at our institution for 20 years. Consider the following: A 24-year-old white. upper-middle-class female presents to her primary care physician for evaluation of weight loss and amenorrhea. For the past year, she has been pursuing a diet of 400 to 600 calories daily and has occasionally used laxatives and self-induced vomiting when she had "eaten too much." She has not had a menstrual period in 9 months. She adamantly refuses requests by her family and friends that she gain some weight. She also refuses to see a psychiatrist because she "is not crazy." Her past medical and psychosocial history is relatively unremarkable, with no demonstrable source of conflict. During her adolescence she was characterized as being somewhat withdrawn and occasionally given to food rituals and periods of intense physical exercise. She also frequently complained of being fat. Her husband is desperate and claims that he has "tried everything" to get her to pay attention to her health.
Presented with such an alarming and difficult clinical picture, what can the primary care physician do? Although the initial temptation for the primary care physician faced with such a patient would be to refer this individual to a psychiatric colleague, we feel that there is an appropriate role for the primary care physician in the management of these difficult patients. We will discuss this role in terms of seven tasks that the primary care physician can undertake to help his or her patient. Task 1: Establish the Seriousness of the Condition The initial task for the physician is to establish the seriousness of the condition. l .2 Patients with anorexia nervosa and bulimia may strenuously resist medical consultation and may be brought in only when they become quite ill. A starved patient with anorexia nervosa who has been a victim of "grayouts" may succumb to VOLUME 32· NUMBER 2· SPRING 1991
Received July 12, 1990; revised November 13, 1990; accepted January 29,1991. From the Depanment of Adolescent and Young Adult Medicine, Children's National Medical Center; and from the Depanment of Pediatrics, George Washington University School of Medicine and Health Sciences. Address reprint requests to Dr. Silber. Department of Adolescent and Young Adult Medicine. Children's National Medical Center, III Michigan Avenue, N.W., Washington, DC 20010. Copyright © 1991 The Academy of Psychosomatic Medicine.
221
Anorexia Nervosa
malnutrition. A "vomiting anorexic" may be moribund due to an electrolyte imbalance. Patients with bradycardia and/or arrhythmia need immediate and appropriate evaluation with an electrocardiogram in order to detect hypokalemia, which can be fatal. A patient who abuses laxatives may be seen with a chief complaint of blood in the stool or melena. Dehydrated patients may be orthostatic and/or present with an episode of syncope. On the other hand, patients who drink profusely in order to "fake" weight gain on medical checkups may develop seizures as a consequence of water intoxication. Amenorrhea is of no immediate concern, yet over time it raises the worrisome possibility of osteopenia. 3 The primary care physician must also be alert to concomitant conditions that may influence the seriousness of their patient's condition, such as the ingestion of amphetamine and ipecac abuse. It is also imperative to assess the patient for the presence and magnitude of depression and hopelessness, and to identify the suicidal patient. Task 2: Evaluate and Treat Nutritional Deficits The next task for the primary care physician is to evaluate and treat the patient's nutritional deficits. 4 Patients with anorexia nervosa and many patients with bulimia present a typical nutritional profile that can be documented clinically by recording vital signs, daily activity, anthropometric measurements, and biochemical data. It is useful to get weight histories and to observe patient photographs from many years. Every doctor needs to become familiar with percentage variation from ideal body weight and to take into account the patient's body frame. Clinical observations that point to nutritional deprivation include bradycardia, hypotension, hypothermia, hair loss, and the growth of lanugo hair. Information should be obtained regarding the patient's menstrual status and his or her ability to sleep. The anthropometric measurements should include a careful assessment of the height, weight, and triceps skin fold thickness, as well as a calculation of the Body Mass Index (BMI). This latter measure provides a gauge of the nutritional status that is both objective and easy to ascertain. 222
The BMI is obtained by dividing weight (kg) by square height (m). A BMI of 16 or less is characteristic of anorexia nervosa. For those interested in an assessment of lean body mass, this can be derived by measuring the mid-arm muscle circumference. This measurement is arrived at by subtracting the triceps skin fold in millimeters from the arm circumference in centimeters, and by multiplying the resulting number by 0.314. There are a variety of biochemical measures of nutritional status for which an eating disorder patient should be screened. Prealbumin is an excellent marker for nutritional status and is more sensitive than serum albumin, which, although commonly used to assess the visceral protein compartment, is rarely abnormal except in the most extreme cases of malnutrition. Another sensitive indicator of protein caloric malnutrition is serum transferrin, which has a half-life of9 days, as opposed to albumin, which has a half-life of 20 days. However, a transferrin level may not be useful in patients with iron deficiency anemia. Transferrin values may be obtained by dividing the total iron binding capacity (J.lg/loo ml) by 1.45 and expressing the results as mgtI00 ml. Some laboratories can now quantify transferrin by immunologic methods. Triiodothyronine (T3)' the bioactive form of thyroid hormone, can be remarkably low in starvation states. The presence of a concomitant low thyroid stimulating hormone (TSH) rules out hypothyroidism. Malnourished patients often have leukopenia and a low total lymphocyte count. A total lymphocyte count below 1,500 is considered abnormal. Some patients with anorexia nervosa have been noted to have overall problems in immune function, such as delayed hypersensitivity reactions and depressed T-eelllymphocyte counts. The electrocardiogram can be helpful in detecting hypokalemia (low T wave), arrhythmia, and prolongation of the QT interval, all of which have been associated with sudden death in patients with anorexia nervosa. 2 Task 3: Establish Differential Diagnosis The third task that the primary care physician must undertake as part of the evaluation of paPSYCHOSOMATICS
Silber and D'Angelo
tients with malnutrition is to detennine which other diagnoses need to be considered. These may include organic and psychiatric conditions that are capable of producing weight loss, malnutrition, and abnonnal eating behaviors. In the absence of a classic history of anorexia nervosa, other possibilities to consider are disorders of the gastrointestinal tract, endocrine system, and central nervous system, as well as chronic infection and malignancy. A careful history and physical examination complemented by specific wellchosen laboratory studies usually can distinguish an eating disorder such as anorexia nervosa from the other diagnostic possibilities. For example, malabsorption syndromes causing severe weight loss are often associated with steatorrhea, bloating, and hypoproteinemia. Regional enteritis, on the other hand, is often accompanied by anemia, high erythrocyte sedimentation rate, and occult blood in the stool. Hyperthyroidism can also present with severe weight loss. Yet in the case of patients who are hyperthyroid, increased hunger and food intake are common, and vital signs reveal tachycardia and hypertension, both of which are not present in patients with anorexia nervosa. Cocaine use can produce emaciation but can be identified by life-style history and/or drug screen. Finally, malignancies and chronic infections, such as tuberculosis, chronic pylonephritis, and occult abscesses, are usually associated with some other laboratory abnonnalities, such as elevated sedimentation rates, abnonnalities in hemoglobin and hematocrit, or elevation of the white blood cell count. The actual number of tests necessary to establish an appropriate differential diagnosis will vary, depending on the point in time at which the primary care physician is consulted and the degree to which he or she is familiar with the symptoms of eating disorders. We advocate only a minimal laboratory workup. In the typical case it is probably sufficient to obtain a complete blood count, a urinalysis, a sedimentation rate, and a multichannel blood chemistry evaluation. Additional measurements, such as assessment of bone density, may be helpful in patients who have experienced prolonged amenorrhea. Certain laboratory abnonnalities can be seen VOLUME 32· NUMBER 2· SPRING 199\
in the patient with eating disorders. These include an elevated hemoglobin and hematocrit (secondary to hemoconcentration), leukopenia (secondary to malnutrition), a low sedimentation rate, chemical evidence of metabolic alkalosis with hypokalemia (found in patients who are vomiting), a low serum T3 level, a low serum transferrin, and an electrocardiogram showing significant bradycardia. 2.5 Additional tests that have been advocated by other authors include a pelvic examination, a skin test for tuberculosis, morning and evening cortisol levels, measurement of luteinizing honnone and follicle-stimulating honnone, a prolactin assay, a cranial cr scan with contrast, and a complete gastrointestinal radio!raphic x-ray, including upper GI series with small bowel followth~ough.6 These are probably best reserved for patients in whom abnonnalities of physical exam or other lab tests raise other diagnostic possibilities. Task 4: Help to Decide if and When Hospitalization Is Necessary The primary care physician should help to decide when hospitalization is necessary. This may be undertaken under the auspices of a consulting psychiatrist or another primary care or subspecialty practitioner familiar with the treatment of patients with eating disorders. Criteria that often indicate the need for hospitalization include I) a history of visual disturbance ("grayout") or syncope; 2) heart rate of less than 55 beats per minute in a nonathlete or the presence of cardiac arrhythmia; 3) acute starvation; 4) total body weight of less than 75% of predicted optimal for that specific patient; 5) intractable vomiting; and 6) persistent weight loss in the face of appropriate outpatient treatment. The primary care physician may also recognize psychosocial aspects that may influence a decision to hospitalize the patient. These include I) severe depression, with or without suicidal ideation; 2) chronicity of symptoms with no therapeutic gains, despite appropriate treatment; and 3) a severe relapse in a patient who had previously recovered. 223
.~.
- ,-
Anorexia Nervosa
Task 5: Interpret the Course of Therapy and Influence Mental Health Referral The fifth task which the primary care physician should undertake in the treatment of patients with eating disorders is explaining to the patient and to the family the course of the recommended treatment. Although there are numerous theories about the pathogenesis of eating disorders, at this time there is still not a clear understanding of the contribution of both psychological and biological factors in the development of this condition in a particular patient. What is known and can be shared with a patient and his or her family is that I) it appears that a combination of behavioral disturbances (weight phobia, addiction to starvation, laxative abuse, or vomiting) play a major role; 2) a variety of physiologic disturbances are known also to be associated with eating disorders (delayed gastric emptying, amenorrhea, ketosis); and 3) the condition is accompanied by psychological disturbances that are related to starvation and malnutrition, as well as to issues of adolescent and young adult development. The mental health consultation is best obtained by presenting it as needed for evaluation and treatment of those symptoms that are most distressing to the patient (e.g., anxiety, insomnia, problems of living). The family involvement should be equally proposed in terms of problem solving. For these reasons it is helpful to obtain the patient's (and family's) personal theory of disease. Only if we first listen and understand them can we successfully encourage them to follow through with our recommendations afterwards. 7 When presenting the need for psychiatric assessment, it is important that the primary care physician be sensitive and pay attention in order to reduce the feelings of paralyzing guilt often felt by both the patients and their families. 8 The goal of a primary care physician should be to promote a careful individualized assessment and to persuade the patient to obtain appropriate psychotherapy (individual, group, family) in a timely manner. It is important that the primary care physician help the patient understand that the medical follow-up is recommended in addition to the psychiatric care, rather than instead of it. This 224
needs to be done in such a manner that the patient will not feel abandoned. The clinician needs to provide appropriate support for the patient and not be alienated by the patient's irrational anorexic stance in an effort to avoid a power struggle that could ultimately result in the patient's sabotage of all treatment efforts. Task 6: Serve as Health Educator for Patient and Family An important task for the primary physician is to carefully instruct the patient and his or her family concerning health education. Appropriate topics for discussion include general health, nutrition, fertility, and the need or desirability of medication (estrogen, multivitamins, psychopharmaceuticals). Underlying all educational efforts should be the thought that the condition, though dangerous, is reversible with appropriate treatment and with "a lot of hard work on everybody's part." The patient should be repeatedly assured that "I will not let you die, and I will not let you get fat." The goal is to present aspects of reality that may be helpful to the ongoing work of the mental health colleague who is treating the patient. At some moment during the patient's overall treatment, he or she may be able to use the information given, but even before the patient does, the physician's counseling may convey an attitude of caring and respect. This educational intervention can be augmented with referral to existing organizations, such as the National Anorexia Aid Society.
Task 7: Coordinate Treatment Team Activities The final task that the primary care physician needs to undertake is to become familiar with the entire team involved in the treatment in order to avoid manipulation, splitting, and confusion. 9 Regularconversations with psychotherapists, nutritionists, and others involved in the care of the patient in either an inpatient or outpatient setting are important. A good rapport between physician and therapist is crucial. Ideally, the psychotherapist should be willing to accept and respect the PSYCHOSOMATICS
·...r -
Silber and D'Angelo
emotional support that the physician can provide to the patient, while the physician should realize that there are times when he or she should communicate with the mental health colleague to make sure that all information necessary to treat the patient has been made available.
It is precisely this availability, endurance, and teamwork-all within a framework of structure and caring-that will result in the cure of many patients and improve the health and overall functioning of most others.
References I. Silber TJ: Anorexia nervosa: morbidity and mortality. Pediatr Ann 13:886-890, 1984 2. Hertzog DB, Copeland PM: Eating Disorders. N Engl J Med 313:295-303, 1985
3. Silber TJ, Cox 1M: Early detection of osteopenia in anorexia nervosa by radiographic absorptiometry. Adolescent and Pediatric Gynecology 3: 137-14{), 1990 4. Beaumont P, AI-Alami M, Touyz S: Reference of a standard measurement of undernutrition to the diagnosis of anorexia nervosa: use of Quetlet's Body Mass Index (BMI). InternationalJournal o/Eating Disorders 7:399-
4{)5. 1988 5. Pomeroy C, Mitchell1£: Medical complications and man-
VOLUME 32· NUMBER 2. SPRING 1991
agement of eating disorders. Psychiatric Annals 19:488493, 1989 6. Doering EJ: The role of the primary care physician in the diagnosis and management of anorexia nervosa, in Anorexia Nervosa. Edited by Gross M. Lexington, Collamore Press, 1982, pp 15-25 7. Beitman BD, Featherstone H, Kastner L, et al: Steps toward patient acknowledgment of psychosocial factors. J Fam Pract 15: 1119-1126, 1982 8. PauJcer N: Parental and childhood resistance to therapy for eating disorders. Pediatr Ann 13:892-897, 1984 9. Tinker D, Ramer JC: Anorexia nervosa: staff subversion of therapy. J Adolesc Health Care 4:35-39, 1983
225
ThiS article discusses the appropriate role of the nonpsychiatric primary physician in the initial management and ongoing care of patients afflicted with anorexia nervosa. It is based on the experiences of both individual practitioners and members of a multidisciplinary eating disorders program that has been in existence at our institution for 20 years. Consider the following: A 24-year-old white. upper-middle-class female presents to her primary care physician for evaluation of weight loss and amenorrhea. For the past year, she has been pursuing a diet of 400 to 600 calories daily and has occasionally used laxatives and self-induced vomiting when she had "eaten too much." She has not had a menstrual period in 9 months. She adamantly refuses requests by her family and friends that she gain some weight. She also refuses to see a psychiatrist because she "is not crazy." Her past medical and psychosocial history is relatively unremarkable, with no demonstrable source of conflict. During her adolescence she was characterized as being somewhat withdrawn and occasionally given to food rituals and periods of intense physical exercise. She also frequently complained of being fat. Her husband is desperate and claims that he has "tried everything" to get her to pay attention to her health.
Presented with such an alarming and difficult clinical picture, what can the primary care physician do? Although the initial temptation for the primary care physician faced with such a patient would be to refer this individual to a psychiatric colleague, we feel that there is an appropriate role for the primary care physician in the management of these difficult patients. We will discuss this role in terms of seven tasks that the primary care physician can undertake to help his or her patient. Task 1: Establish the Seriousness of the Condition The initial task for the physician is to establish the seriousness of the condition. l .2 Patients with anorexia nervosa and bulimia may strenuously resist medical consultation and may be brought in only when they become quite ill. A starved patient with anorexia nervosa who has been a victim of "grayouts" may succumb to VOLUME 32· NUMBER 2· SPRING 1991
Received July 12, 1990; revised November 13, 1990; accepted January 29,1991. From the Depanment of Adolescent and Young Adult Medicine, Children's National Medical Center; and from the Depanment of Pediatrics, George Washington University School of Medicine and Health Sciences. Address reprint requests to Dr. Silber. Department of Adolescent and Young Adult Medicine. Children's National Medical Center, III Michigan Avenue, N.W., Washington, DC 20010. Copyright © 1991 The Academy of Psychosomatic Medicine.
221
Anorexia Nervosa
malnutrition. A "vomiting anorexic" may be moribund due to an electrolyte imbalance. Patients with bradycardia and/or arrhythmia need immediate and appropriate evaluation with an electrocardiogram in order to detect hypokalemia, which can be fatal. A patient who abuses laxatives may be seen with a chief complaint of blood in the stool or melena. Dehydrated patients may be orthostatic and/or present with an episode of syncope. On the other hand, patients who drink profusely in order to "fake" weight gain on medical checkups may develop seizures as a consequence of water intoxication. Amenorrhea is of no immediate concern, yet over time it raises the worrisome possibility of osteopenia. 3 The primary care physician must also be alert to concomitant conditions that may influence the seriousness of their patient's condition, such as the ingestion of amphetamine and ipecac abuse. It is also imperative to assess the patient for the presence and magnitude of depression and hopelessness, and to identify the suicidal patient. Task 2: Evaluate and Treat Nutritional Deficits The next task for the primary care physician is to evaluate and treat the patient's nutritional deficits. 4 Patients with anorexia nervosa and many patients with bulimia present a typical nutritional profile that can be documented clinically by recording vital signs, daily activity, anthropometric measurements, and biochemical data. It is useful to get weight histories and to observe patient photographs from many years. Every doctor needs to become familiar with percentage variation from ideal body weight and to take into account the patient's body frame. Clinical observations that point to nutritional deprivation include bradycardia, hypotension, hypothermia, hair loss, and the growth of lanugo hair. Information should be obtained regarding the patient's menstrual status and his or her ability to sleep. The anthropometric measurements should include a careful assessment of the height, weight, and triceps skin fold thickness, as well as a calculation of the Body Mass Index (BMI). This latter measure provides a gauge of the nutritional status that is both objective and easy to ascertain. 222
The BMI is obtained by dividing weight (kg) by square height (m). A BMI of 16 or less is characteristic of anorexia nervosa. For those interested in an assessment of lean body mass, this can be derived by measuring the mid-arm muscle circumference. This measurement is arrived at by subtracting the triceps skin fold in millimeters from the arm circumference in centimeters, and by multiplying the resulting number by 0.314. There are a variety of biochemical measures of nutritional status for which an eating disorder patient should be screened. Prealbumin is an excellent marker for nutritional status and is more sensitive than serum albumin, which, although commonly used to assess the visceral protein compartment, is rarely abnormal except in the most extreme cases of malnutrition. Another sensitive indicator of protein caloric malnutrition is serum transferrin, which has a half-life of9 days, as opposed to albumin, which has a half-life of 20 days. However, a transferrin level may not be useful in patients with iron deficiency anemia. Transferrin values may be obtained by dividing the total iron binding capacity (J.lg/loo ml) by 1.45 and expressing the results as mgtI00 ml. Some laboratories can now quantify transferrin by immunologic methods. Triiodothyronine (T3)' the bioactive form of thyroid hormone, can be remarkably low in starvation states. The presence of a concomitant low thyroid stimulating hormone (TSH) rules out hypothyroidism. Malnourished patients often have leukopenia and a low total lymphocyte count. A total lymphocyte count below 1,500 is considered abnormal. Some patients with anorexia nervosa have been noted to have overall problems in immune function, such as delayed hypersensitivity reactions and depressed T-eelllymphocyte counts. The electrocardiogram can be helpful in detecting hypokalemia (low T wave), arrhythmia, and prolongation of the QT interval, all of which have been associated with sudden death in patients with anorexia nervosa. 2 Task 3: Establish Differential Diagnosis The third task that the primary care physician must undertake as part of the evaluation of paPSYCHOSOMATICS
Silber and D'Angelo
tients with malnutrition is to detennine which other diagnoses need to be considered. These may include organic and psychiatric conditions that are capable of producing weight loss, malnutrition, and abnonnal eating behaviors. In the absence of a classic history of anorexia nervosa, other possibilities to consider are disorders of the gastrointestinal tract, endocrine system, and central nervous system, as well as chronic infection and malignancy. A careful history and physical examination complemented by specific wellchosen laboratory studies usually can distinguish an eating disorder such as anorexia nervosa from the other diagnostic possibilities. For example, malabsorption syndromes causing severe weight loss are often associated with steatorrhea, bloating, and hypoproteinemia. Regional enteritis, on the other hand, is often accompanied by anemia, high erythrocyte sedimentation rate, and occult blood in the stool. Hyperthyroidism can also present with severe weight loss. Yet in the case of patients who are hyperthyroid, increased hunger and food intake are common, and vital signs reveal tachycardia and hypertension, both of which are not present in patients with anorexia nervosa. Cocaine use can produce emaciation but can be identified by life-style history and/or drug screen. Finally, malignancies and chronic infections, such as tuberculosis, chronic pylonephritis, and occult abscesses, are usually associated with some other laboratory abnonnalities, such as elevated sedimentation rates, abnonnalities in hemoglobin and hematocrit, or elevation of the white blood cell count. The actual number of tests necessary to establish an appropriate differential diagnosis will vary, depending on the point in time at which the primary care physician is consulted and the degree to which he or she is familiar with the symptoms of eating disorders. We advocate only a minimal laboratory workup. In the typical case it is probably sufficient to obtain a complete blood count, a urinalysis, a sedimentation rate, and a multichannel blood chemistry evaluation. Additional measurements, such as assessment of bone density, may be helpful in patients who have experienced prolonged amenorrhea. Certain laboratory abnonnalities can be seen VOLUME 32· NUMBER 2· SPRING 199\
in the patient with eating disorders. These include an elevated hemoglobin and hematocrit (secondary to hemoconcentration), leukopenia (secondary to malnutrition), a low sedimentation rate, chemical evidence of metabolic alkalosis with hypokalemia (found in patients who are vomiting), a low serum T3 level, a low serum transferrin, and an electrocardiogram showing significant bradycardia. 2.5 Additional tests that have been advocated by other authors include a pelvic examination, a skin test for tuberculosis, morning and evening cortisol levels, measurement of luteinizing honnone and follicle-stimulating honnone, a prolactin assay, a cranial cr scan with contrast, and a complete gastrointestinal radio!raphic x-ray, including upper GI series with small bowel followth~ough.6 These are probably best reserved for patients in whom abnonnalities of physical exam or other lab tests raise other diagnostic possibilities. Task 4: Help to Decide if and When Hospitalization Is Necessary The primary care physician should help to decide when hospitalization is necessary. This may be undertaken under the auspices of a consulting psychiatrist or another primary care or subspecialty practitioner familiar with the treatment of patients with eating disorders. Criteria that often indicate the need for hospitalization include I) a history of visual disturbance ("grayout") or syncope; 2) heart rate of less than 55 beats per minute in a nonathlete or the presence of cardiac arrhythmia; 3) acute starvation; 4) total body weight of less than 75% of predicted optimal for that specific patient; 5) intractable vomiting; and 6) persistent weight loss in the face of appropriate outpatient treatment. The primary care physician may also recognize psychosocial aspects that may influence a decision to hospitalize the patient. These include I) severe depression, with or without suicidal ideation; 2) chronicity of symptoms with no therapeutic gains, despite appropriate treatment; and 3) a severe relapse in a patient who had previously recovered. 223
.~.
- ,-
Anorexia Nervosa
Task 5: Interpret the Course of Therapy and Influence Mental Health Referral The fifth task which the primary care physician should undertake in the treatment of patients with eating disorders is explaining to the patient and to the family the course of the recommended treatment. Although there are numerous theories about the pathogenesis of eating disorders, at this time there is still not a clear understanding of the contribution of both psychological and biological factors in the development of this condition in a particular patient. What is known and can be shared with a patient and his or her family is that I) it appears that a combination of behavioral disturbances (weight phobia, addiction to starvation, laxative abuse, or vomiting) play a major role; 2) a variety of physiologic disturbances are known also to be associated with eating disorders (delayed gastric emptying, amenorrhea, ketosis); and 3) the condition is accompanied by psychological disturbances that are related to starvation and malnutrition, as well as to issues of adolescent and young adult development. The mental health consultation is best obtained by presenting it as needed for evaluation and treatment of those symptoms that are most distressing to the patient (e.g., anxiety, insomnia, problems of living). The family involvement should be equally proposed in terms of problem solving. For these reasons it is helpful to obtain the patient's (and family's) personal theory of disease. Only if we first listen and understand them can we successfully encourage them to follow through with our recommendations afterwards. 7 When presenting the need for psychiatric assessment, it is important that the primary care physician be sensitive and pay attention in order to reduce the feelings of paralyzing guilt often felt by both the patients and their families. 8 The goal of a primary care physician should be to promote a careful individualized assessment and to persuade the patient to obtain appropriate psychotherapy (individual, group, family) in a timely manner. It is important that the primary care physician help the patient understand that the medical follow-up is recommended in addition to the psychiatric care, rather than instead of it. This 224
needs to be done in such a manner that the patient will not feel abandoned. The clinician needs to provide appropriate support for the patient and not be alienated by the patient's irrational anorexic stance in an effort to avoid a power struggle that could ultimately result in the patient's sabotage of all treatment efforts. Task 6: Serve as Health Educator for Patient and Family An important task for the primary physician is to carefully instruct the patient and his or her family concerning health education. Appropriate topics for discussion include general health, nutrition, fertility, and the need or desirability of medication (estrogen, multivitamins, psychopharmaceuticals). Underlying all educational efforts should be the thought that the condition, though dangerous, is reversible with appropriate treatment and with "a lot of hard work on everybody's part." The patient should be repeatedly assured that "I will not let you die, and I will not let you get fat." The goal is to present aspects of reality that may be helpful to the ongoing work of the mental health colleague who is treating the patient. At some moment during the patient's overall treatment, he or she may be able to use the information given, but even before the patient does, the physician's counseling may convey an attitude of caring and respect. This educational intervention can be augmented with referral to existing organizations, such as the National Anorexia Aid Society.
Task 7: Coordinate Treatment Team Activities The final task that the primary care physician needs to undertake is to become familiar with the entire team involved in the treatment in order to avoid manipulation, splitting, and confusion. 9 Regularconversations with psychotherapists, nutritionists, and others involved in the care of the patient in either an inpatient or outpatient setting are important. A good rapport between physician and therapist is crucial. Ideally, the psychotherapist should be willing to accept and respect the PSYCHOSOMATICS
·...r -
Silber and D'Angelo
emotional support that the physician can provide to the patient, while the physician should realize that there are times when he or she should communicate with the mental health colleague to make sure that all information necessary to treat the patient has been made available.
It is precisely this availability, endurance, and teamwork-all within a framework of structure and caring-that will result in the cure of many patients and improve the health and overall functioning of most others.
References I. Silber TJ: Anorexia nervosa: morbidity and mortality. Pediatr Ann 13:886-890, 1984 2. Hertzog DB, Copeland PM: Eating Disorders. N Engl J Med 313:295-303, 1985
3. Silber TJ, Cox 1M: Early detection of osteopenia in anorexia nervosa by radiographic absorptiometry. Adolescent and Pediatric Gynecology 3: 137-14{), 1990 4. Beaumont P, AI-Alami M, Touyz S: Reference of a standard measurement of undernutrition to the diagnosis of anorexia nervosa: use of Quetlet's Body Mass Index (BMI). InternationalJournal o/Eating Disorders 7:399-
4{)5. 1988 5. Pomeroy C, Mitchell1£: Medical complications and man-
VOLUME 32· NUMBER 2. SPRING 1991
agement of eating disorders. Psychiatric Annals 19:488493, 1989 6. Doering EJ: The role of the primary care physician in the diagnosis and management of anorexia nervosa, in Anorexia Nervosa. Edited by Gross M. Lexington, Collamore Press, 1982, pp 15-25 7. Beitman BD, Featherstone H, Kastner L, et al: Steps toward patient acknowledgment of psychosocial factors. J Fam Pract 15: 1119-1126, 1982 8. PauJcer N: Parental and childhood resistance to therapy for eating disorders. Pediatr Ann 13:892-897, 1984 9. Tinker D, Ramer JC: Anorexia nervosa: staff subversion of therapy. J Adolesc Health Care 4:35-39, 1983
225
