Medical Management Of Anorexia Nervosa And Bulimia Nervosa - Anorexia Nervosa And Bulimia Nervosa Treatment

Written by HealthyPlace.com Staff Writer

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.