Note: This chapter is written to benefit both professional and nonprofessional readers and is geared specifically to anorexia nervosa and bulimia nervosa. The reader is referred to other sources for information on binge eating disorder. An overview of the general medical concerns of these eating disorders is provided, as well as guidelines for a thorough medical assessment, including laboratory tests that must be performed. An in-depth discussion of the problems related to amenorrhea and bone density has also been added to this most recent edition.

Of the entire gamut of psychological disorders treated by clinicians, anorexia nervosa and bulimia nervosa are the ones most frequently punctuated by accompanying medical complications. Although many of these are more annoying than serious, a distinct number of them are indeed potentially life threatening. The mortality rate for these disorders exceeds that found in any other psychiatric illness and approaches 20 percent in the advanced stages of anorexia nervosa. Thus, a clinician cannot simply assume that the physical symptoms associated with these eating disorders are just functional in origin. Physical complaints must be judiciously investigated and organic disease systematically excluded by appropriate tests. Conversely, it is important, from a treatment vantage point, to avoid subjecting the patient to expensive, unnecessary, and potentially invasive tests.

Competent and comprehensive care of eating disorders must involve understanding the medical aspects of these illnesses, not just for physicians but for any clinician treating them, regardless of discipline or orientation. A therapist must know what to look for, what certain symptoms might mean, and when to send a patient for an initial medical evaluation as well as for follow-up. A dietitian will likely be the team member who performs the nutrition evaluation, instead of the physician, and must have adequate knowledge of all medical/nutritional aspects of eating disorders. A psychiatrist may prescribe medication for an underlying mood or thought disorder and must coordinate this with the rest of the treatment.

The medical complications that arise vary with each individual. Two persons with the same behaviors may develop completely different physical symptoms or the same symptoms within different time frames. Some patients who self-induce vomiting have low electrolytes and a bleeding esophagus; others can vomit for years without ever developing these symptoms. People have died from ingesting ipecac or excessive pressure on their diaphragms from a binge, while others have performed these same behaviors with no evidence of medical complications. It is critical to keep this in mind. A bulimic woman who binges and vomits eighteen times a day or a 79-pound anorexic can both have normal lab results. It is necessary to have a well-trained and experienced physician as part of the treatment of an eating disordered patient. Not only do these physicians have to treat symptoms that they find, but they have to anticipate what is to come, and discuss what is not revealed by medical lab data.

A physician treating a patient with an eating disorder needs to know what to look for and what laboratory or other tests to perform. The physician must have some empathy and understanding of the overall picture involved in an eating disorder to avoid minimizing symptoms, misunderstanding, or giving conflicting advice. Unfortunately, physicians with special training and/or experience in diagnosing and treating eating disorders are not very common, and furthermore, patients who seek psychotherapy for an eating disorder often have their own family doctors they may prefer to use rather than one the therapist refers them to. Physicians not trained in eating disorders may overlook or disregard certain findings to the detriment of the patient. In fact, eating disorders often go undetected for long periods of time even when the individual has been to a physician. Weight loss of unknown origin, failure to grow at a normal rate, unexplained amenorrhea, hypothyroid or high cholesterol can all be signs of undiagnosed anorexia nervosa that physicians too often fail to act on or attribute to other causes. Patients have been known to have loss of dental enamel, parotid gland enlargement, damaged esophagi, high serum amylase levels, and scars on the back of the hand from self-induced vomiting, and yet still be undiagnosed with bulimia nervosa!

Although there is clearly a continuum in the spectrum of physical illnesses encountered in anorexia and bulimia, with much clinical overlap, the discussions of anorexia and bulimia and their unique medical complications are also useful.

ANOREXIA NERVOSA

Most medical complications in anorexia are a direct result of weight loss. There are a number of easily observable skin abnormalities that are seen including brittle nails, thinning hair, yellow-tinged skin, and a fine downy growth of hair on the face, back, and arms, which is referred to as lanugo hair. All of these changes revert to normal with weight restoration. There are other, more serious complications involving a variety of systems in the body.

Most anorexics can be treated as outpatients. Inpatient hospitalization is recommended for patients whose weight loss is rapidly progressive or whose weight loss is greater than 30 percent of ideal body weight, as well as for those with cardiac arrhythmias or symptoms of inadequate blood flow to the brain.