Medical Management Of Anorexia Nervosa And Bulimia Nervosa

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DIURETICS

Another mode of purging that can produce medical problems is the abuse of diuretics. This mode is infrequently utilized except by medical personnel who may have access to these medications, although they are also available in over-the-counter preparations containing pamabrom, caffeine, or ammonium chloride. The main complication associated with diuretic abuse is fluid and electrolyte imbalance. In fact, the electrolyte pattern is basically the same as that seen with self-induced vomiting, which is potentially dangerous due to heart problems caused by low potassium levels.

There is also a reflexive development of lower leg edema (swelling) with abrupt cessation of diuretic abuse. Generally the edema can be controlled and treated with salt restriction and leg elevation. It is worthwhile to give a brief educational talk to patients with edema explaining that the condition is self-limited and caused by a reaction from the body which diuretics promote, albeit transiently.

DIET PILLS/APPETITE SUPPRESSANTS

Another method used to avoid weight gain and/or promote weight loss is the use of diet pills. Diet pills are not actually considered a form of purging but are used as a compensatory reaction to binge eating in the category of bulimia nervosa known as "nonpurging type." Most diet pills stimulate the sympathetic nervous system and are amphetamine-type derivatives. The adverse effects of diet pills include hypertension (high blood pressure), palpitations, seizures, and anxiety attacks. There is no long-term dependence syndrome associated with the usage of diet pills, and abrupt cessation is medically safe.

Individuals suffering from anorexia nervosa or bulimia nervosa may be troubled with a myriad of medical complications. However, with proper identification and an effective and safe treatment plan, most of these are reversible. Medical management may thus be the building block for a successful psychiatric treatment program.

GUIDELINES FOR MEDICAL EVALUATION

GENERAL SIGNS AND SYMPTOMS

Aside from an emaciated look in anorexia nervosa, it may be difficult to detect health problems in individuals with eating disorders, especially in the early stages of the illness. Over time, however, individuals who are starving, purging, or taxing the body through excessive exercise take on a generally lackluster appearance.

On close inspection, one can notice things such as dry skin or blotchy red marks on the skin, dry hair, thinning of hair at the scalp, or a general loss of hair altogether. On the other hand, growth of downy hair (lanugo) on the arms or stomach can be detected in extremely thin patients as the body responds to protect itself from the cold when it lacks body fat as an isulator.

One should look for broken blood vessels in the eyes and for swelling of the parotid gland (in the neck below the ear and behind the cheek bone), which is caused by vomiting. Swollen parotid glands are often visible, but they can also be discovered by palpating the parotid glands to check for enlargement. Hypothermia, low body temperature, and bradycardia (irregular pulse) are also common and should be investigated and monitored closely.

All patients should be questioned about and examined for hair loss; cold intolerance; dizziness; fatigue; cracked lips; oligomenorrhea (irregular menstruation) or amenorrhea (lack of menstruation); sleep disturbance; constipation; diarrhea; abdominal bloating, pain, or distension; esophageal reflux; dental erosion; poor concentration; and headaches.

A thorough physical should include questions about the patient's general diet, as well as her preoccupation with food, food fears, carbohydrate craving, and nighttime eating. Asking about these things helps indicate to the patient that all of these issues may directly affect his health.

The physician should also inquire about symptoms related to anxiety (e.g., racing heartbeat, sweaty palms, and nail biting), depression (e.g., hypersomnia and frequent crying spells or thoughts of suicide), obsessive-compulsive disorder (e.g., constantly weighing oneself or food, having to have clothes or other things in a perfect order, obsessing about germs or cleanliness, and having to do things in a certain order or at certain times only). Knowing about these conditions is essential if the physician, as well as the treatment team, are to fully understand the clinical status of each individual and develop a thorough treatment plan.

LABORATORY AND OTHER MEDICAL TESTS

It is important that a physician orders an "eating disorder laboratory panel" as part of the medical assessment. This panel of tests will include those not routinely performed in a physical exam but which should be done with an eating disordered patient.

Tests generally recommended include:

• A complete blood count (CBC). This will give an analysis of the red and white blood cells in terms of their quantity, type, and size, as well as the different types of white cells and the amount of hemoglobin in the red cells. Chem-20 panel. There are several different panels to run, but the Chem-20 is a common one that includes a variety of tests to measure liver, kidney, and pancreatic function. Total protein and albumin, calcium, and sedementation rates should be included. Serum amylase. This test is another indicator of pancreatic function and is useful when it is suspected that a client is purging and the client continues to deny it. Thyroid and parathyroid panel. This should include T3, T4, T7, and TSH (thyroid-stimulating hormone). These tests measure the thyroid and pituitary glands and indicate the level of metabolic function. Other hormones. Estrogen, progesterone, testosterone, estradiol, luteinizing hormone, and follicle-stimulating hormone are all affected by eating disorder behaviors. Which of these tests to run and when to run them are the subject of much debate and should be worked out with the physician. Please see "Bone Density" on page 233 for further information. Sma-7 or electrolytes. This test includes sodium (NA+), potassium (K+), chloride (Cl-), bicarbonate (HCO3-), blood urea nitrogen (BUN), and creatinine (Creat). Patients with restrictor anorexia nervosa may show abnormalities in these tests, but electrolyte abnormalities are far more common in individuals with anorexia nervosa who purge or in individuals with bulimia nervosa. Furthermore, specific abnormalities are associated with specific kinds of purging. For example, bulimics who purge with diuretics may have low levels of sodium and potassium and high levels of bicarbonate. Low potassium (hypokalemia) and high bicarbonate (metabolic alkalosis) are the most common electrolyte abnormalities seen in patients who purge either with diuretics or with vomiting; these abnormalities are potentially the most dangerous. Hypokalemia can cause cardiac conduction defects, and arrhythmias and metabolic alkalosis can cause seizures and arrhythmias. Laxative abuse will often, but not always, cause a low potassium level, a low bicarbonate level, and a high chloride level, together referrred to as hyperchloremic metabolic acidosis. Electrocardiogram. The electrocardiogram ( EKG) is a test for measuring heart function. This test will not pick up every possible problem but is a useful indicator of the health of the heart. Other tests should be selectively performed. These include:

Chest X ray. If a patient has chest pain that persists, a chest X ray may be indicated. Abdominal X ray. Occasionally, patients will complain of severe bloating that does not subside. It may be wise to have X rays taken in the event that there is a blockage of some sort. Lower esophageal sphincter pressure studies for reflux. Some patients have spontaneous vomiting or severe indigestion in which food comes back up into the mouth with no forced effort on their part. This should be checked out medically with this test and possibly others recommended by a gastroenterologist. Lactose deficiency tests for dairy intolerance. Patients often complain about the inability to digest dairy products. Sometimes patients develop intolerance, and some may have had a preexisting problem. If the symptoms become too distressing for the client (e.g., excess indigestion, gas, burping, rashes) or if it is suspected that the client is using this as a means of avoiding food intake, a lactose test may help indicate the best way to move forward with the treatment. Total bowel transit time for severe constipation. Patients often complain of constipation, but for the most part this corrects itself with proper diet. Sometimes, as in the case of severe laxative dependency, the constipation is unremitting and goes on for over two weeks or is accompanied by severe cramping and pain. A bowel transit test as well as others recommended by a gastroenterologist may be necessary. Magnesium level. Magnesium is not regularly tested with the electrolytes. However, low levels of magnesium can be very dangerous in relation to heart function. Magnesium levels should be tested, especially if the potassium level is low. Phosphorous level. Phosphorous levels are not routinely tested and are usually normal in the early stages of an eating disorder. Abnormal levels of phosphorous are more likely to be found in anorexia nervosa, particularly during refeeding, as it is removed from the serum and incorporated into the new proteins being synthesized. If phosphorous levels go unchecked and get too low, the patient can suffer difficulties with breathing, as well as red blood cell and brain dysfunction. Lab tests should be run a few times per week during refeeding. C-3 complement level, serum ferritin, serum iron, and transferrin saturation level. These four tests are not routinely done in a physical but can be useful with eating disordered patients. They are among the most sensitive tests for protein and iron deficiency and, unlike the CBC and Chem-20, they are frequently below normal in eating disordered clients. C-3 complement is a protein that indicates immune system response, serum ferritin measures stored iron, and serum iron measures iron status. Transferrin is a carrier protein for iron; the transferrin saturation level helps identify the many patients who are in the early stages of bone marrow suppression yet have normal hemoglobin and hematocrit levels. Bone mineral density test. Numerous studies show that deficiency in bone mineral density (bone density) is a common and serious medical complication of eating disorders, particularly anorexia nervosa (for more information, see "Bone Density" on page 233). Low levels of bone density can result in osteopenia (bone mineral deficiency that is one standard deviation below age-matched normals) or osteoporosis (bone mineral deficiency that is more than two standard deviations below normal with pathologic fractures). Bone density problems cannot be determined by cursory inspection but can be determined through testing. Some patients actually take their anorexia more seriously when they are shown objective evidence of its consequences, such as mineral-deficient bones. All patients who meet the criteria for anorexia nervosa, as well as those with bulimia nervosa and a past episode of anorexia nervosa (up to 50 percent of persons with bulimia nervosa), should be tested. Other individuals who may not meet the full criteria for an eating disorder but who have had amenorrhea or intermittent menstrual periods may also need to be tested. There is increasing evidence that males with eating disorders are also likely to have bone density problems and therefore should also be tested as well. Low body weight, low body fat, low testosterone levels, and elevated cortisol levels may play a role in bone density deficiencies in males. For a sensitive and specific way to measure bone density, a DEXA scan is recommended. There is radiation associated with this test, but much less than one would receive from a chest X ray. Females should have DEXA scans plus measurement of hormone levels, particularly estradiol, which seems to be a good indicator for ROM. Men should have DEXA scans plus measurement of testosterone levels. Other tests, such as twenty-four-hour urinary calcium measurements to study calcium intake and absorption, and an osteocalcin study to measure bone activity, may also be considered. It is important for the physician not only to check for any medical complications that must be attended to but also to establish a baseline for future comparisons. It must always be kept in mind that medical tests often fall short of revealing problems until the more advanced stages of the illness. Patients engaging in ultimately dangerous behaviors whose laboratory tests come back normal may get the wrong message. It must be explained to them that the body finds ways to compensate for starvation; for example, decreasing the metabolic rate to conserve energy. It usually takes a long time for the body to break down to the point of serious, life-threatening danger.

Most eating disorder complaints, like headaches, stomachaches, insomnia, fatigue, weakness, dizzy spells, and even fainting do not show up on lab results. Parents, therapists, and doctors too often make the mistake of expecting to scare patients into improving their behaviors by having them get a physical exam in order to discover whatever damage has been done. For one thing, patients are rarely motivated by medical consequences and often have the attitude that being thin is more important than being healthy, or nothing bad is really going to happen to them, or they don't care if it does. Furthermore, patients can appear to be healthy and receive normal lab results even though they have been starving, bingeing, or vomiting for months and, in some cases, years. The following journal entries from patients reveal how disturbing this can be.

When I first was dragged into the doctor's office by my mother when my weight had dropped from 135 to 90 pounds, all my lab tests came back fine! I felt vindicated. I just felt like, "See, I told you so, I'm fine, so leave me alone." My doctor told me then, "You may seem healthy now but these things will show up later. You are doing damage to your body that may not show itself for years." I didn't believe it and even if I did, I felt helpless to do anything about it.

When I went for an exam and lab work I was bingeing and vomiting up to twelve times daily and was also smoking marijuana and snorting cocaine regularly. I was very worried about my health! On the way to the doctor's office I snorted cocaine. When my lab test came back normal, I felt excited thinking, "I can get away with this." In some ways I wish the tests had been worse, I wish they would have scared me, maybe it would have helped me to stop. Now, I feel like since it hasn't done any damage, why stop. I know I am damaging myself, my voice is raspy and my salivary glands are swollen from the constant acid wash of the vomit. My skin is grayish and my hair is falling out, but . . . my lab tests were fine!

A NOTE ON BINGE EATING DISORDER

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Managing binge eating disordered patients most likely involves the same medical considerations to be taken into account when treating obese individuals, such as heart or gallbladder disease, diabetes, high blood pressure, and so on. Most symptoms associated with binge eating will be a result of the accompanying weight gain associated with this disorder. Occasionally people have binged to the point of becoming breathless when their distended stomachs press up on their diaphragms. In very rare cases a medical emergency may occur if the stomach wall becomes so stretched that it is damaged or even tears. The reader is referred to other sources on obesity and binge eating disorder for further information on this topic.

MEDICATION

One last aspect of medical management involves the use of medication to treat the coexisting psychological conditions that cause or contribute to eating disorders. Prescribing and managing this type of medication are sometimes undertaken by the family physician or internist but is more often relegated to a psychiatrist who has special training in psychopharmacology. The information regarding mind- altering medication for use with eating disorders is extensive and is covered in chapter 14.

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