Download Anorexia Nervosa and Bulimia Nervosa

CHAPTER
33
Anorexia Nervosa
and Bulimia Nervosa
Debra K. Katzman and Neville H. Golden
This chapter describes the major eating disorders encountered during adolescence including anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified
(EDNOS). The latter group accounts for most adolescents
seeking treatment for an eating disorder and refers to those
patients not meeting full Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition (DSM-IV) criteria for
either anorexia nervosa or bulimia nervosa. In one study,
using the DSM-IV criteria, >50% of children were classified
as having EDNOS (Nicholls et al., 2000).
ANOREXIA NERVOSA
Anorexia nervosa is an eating disorder that primarily affects adolescent girls and requires a comprehensive and
integrated approach to assessment and treatment. This disorder is a classic biopsychosocial syndrome because the
psychological and physiological manifestations are intertwined. The core features are self-induced weight loss accompanied by distorted body image, intense fear of weight
gain, denial of the seriousness of weight loss, and amenorrhea (absence of at least three consecutive menstrual
periods in the postmenarcheal female). Anorexia nervosa is
subdivided into a restrictive subtype and a binge eating and
purging subtype (Table 33.1). Adolescents diagnosed with
anorexia nervosa are reported to have a good prognosis
with 76% having a full recovery (Strober et al., 1997).
Etiology
The etiology of anorexia nervosa is multifactorial with a
combination of biological, psychological, and sociocultural
factors contributing to the development of the disorder.
The specific etiology may be different for different individuals. The biopsychosocial model for anorexia nervosa described by Lucas (1981) is shown in Figure 33.1. This figure
demonstrates how biological vulnerability, psychological
predisposition, and sociocultural influence precipitate dieting and weight loss in a vulnerable individual. This weight
loss, in turn, leads to malnutrition, which contributes to
the physical, psychological, and emotional changes. Over
the last decade, research has focused on the contributions
of genetics to biological vulnerability, the personality type
associated with anorexia nervosa, and the potential role of
neurotransmitters in the etiology of the disorder.
There is a familial predisposition to eating disorders,
with female relatives most often affected. There is a higher
rate of anorexia nervosa among identical twins compared
to fraternal twins. In addition, relatives of individuals
with an eating disorder are at higher risk of developing
an eating disorder. These findings suggest that genetic
factors may predispose some people to eating disorders.
To date, no single gene or combination of genes have
been identified. Recent research has suggested that certain
areas of the human genome may harbor susceptibility
genes for anorexia nervosa on chromosome 1 (Grice
et al., 2002).
Certain personality traits such as perfectionism, low
self-esteem, obsessionality, social isolation, and feelings of
ineffectiveness often predate the onset of the illness and
persist to a varying degree after recovery. Researchers
have discovered disturbances in a number of different
neurotransmitters including serotonin, norepinephrine,
and dopamine in those with anorexia nervosa. There is
evidence that starvation, binging, and excessive exercising
can lead to changes in neurotransmitters and conversely,
there is evidence that neurotransmitter abnormalities can
lead to these behaviors. The role of disturbances in
transmission of serotonin, a neurotransmitter that is known
to play a role in modulating appetite, obsessional behavior,
and impulsivity, has received particular interest in recent
years. (Kaye et al., 1991, 2003).
Weight concerns and societal emphasis on thinness
are pervasive in westernized societies and adolescent girls
tend to be more vulnerable to these influences. The slim
body ideal is thought to be the key contributor to the
gender differences seen in both anorexia nervosa and
bulimia nervosa. In the typical situation, in a biologically
predisposed individual, feelings of ineffectiveness and loss
of control during adolescence, compounded by societal
pressures to be thin, lead to dieting to obtain a sense of
control. Dieting itself, leads to further preoccupation with
shape and weight, perpetuating the cycle. Many of the
behaviors, physical signs, and symptoms seen in anorexia
nervosa can be attributed to malnutrition.
Epidemiology
1. Prevalence: Most recent data suggest that the estimated
prevalence for anorexia nervosa in young women is 0.3%
to 0.5% (Hoek and van Hoeken, 2003). The incidence
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NUTRITION
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33.1
DSM-IV Diagnostic Criteria for Anorexia Nervosa
1. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss
leading to maintenance of body weight <85% of that expected), or failure to make expected weight gain during
period of growth, leading to body weight <85% of that expected.
2. Intense fear of gaining weight or becoming fat, although underweight.
3. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body shape and
weight on self-evaluation, or denial of the seriousness of current low body weight.
4. In postmenarcheal females, amenorrhea, that is, the absence of at least three consecutive menstrual cycles.
(A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen
administration.)
Specify type
Restricting type: During the current episode of anorexia nervosa, the person has not regularly engaged in binge
eating or purging (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).
Binge eating/purging type: During the current episode of anorexia nervosa, the person has regularly engaged in
binge eating or purging (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).
Reprinted with permission from the American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed.
Text Revision, Copyright, 2000.
rate is estimated at 8 cases per 100,000 population.
Incidence rates for anorexia nervosa are highest in
15- to 19-year-old girls, and have increased dramatically over the last 50 years in this age-group (Lucas
et al., 1999). There are anecdotal reports of increasing presentations in prepubertal children. Rates
for partial syndrome anorexia nervosa are typically
higher.
2. Age: Most eating disorders begin during adolescence
and more than 90% of individuals with eating disorders
are diagnosed before the age of 25 years. The peak age
at onset is midadolescence (13–15 years). However, the
age range for the development of anorexia nervosa is
Biological vulnerability
Genetic, physiological
predisposition
approximately 10 to 25 years old. Increasing numbers of
younger children and adolescents are being referred for
assessment and treatment.
3. Gender: Females are more likely than males to develop
eating disorders. Approximately 85% to 90% of adolescents with eating disorders are female. Recent research
has shown that eating disorders are more widespread in
males than previously thought. In fact, one in eight adolescents with anorexia nervosa younger than 14 years
are boys (Katzman et al., 2005).
4. Comorbidity: Anorexia nervosa may coexist with other
psychiatric conditions such as anxiety disorders, depression, obsessive-compulsive disorder (OCD), and
FIGURE 33.1 Biopsychosocial
model for anorexia nervosa. (From
Lucas AR. Toward the understanding
of anorexia nervosa as a disease
entity. Mayo Clin Proc 1981;56:254,
with permission.)
Pubertal
endocrine
changes
n
eliorati g
Am
Weight
loss
Psychological
predisposition
Early experience
Family influences
Intrapsychic conflict
Personality
change
Malnutrition
Dieting
Mental
changes
Social climate
Societal influences
and expectations
Su
stain i n g
Physiological
changes
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ANOREXIA
substance abuse disorders. It may also coexist with
medical conditions such as diabetes mellitus and cystic
fibrosis.
Risk Factors
Risk factors for anorexia nervosa are factors that do not
seem to be a direct cause of the disorder but increase
the probability of developing the disorder. The absence
of any risk factor or the presence of a protective factor does not necessarily protect one against developing
anorexia nervosa. According to a recent review (Walsh
et al., 2005), potential risk factors predisposing an adolescent to anorexia nervosa include:
1. Age and gender: See preceding text. Anorexia nervosa
usually develops during adolescence. Being female, is
probably the most reliable risk factor for anorexia
nervosa.
2. Early childhood eating problems: Picky eating,
anorexic symptoms in childhood, digestive and early
eating-related problems, eating conflicts, struggles concerning meals are thought to be risk factors for anorexia
nervosa.
3. Weight concerns/negative body image/dieting:
Studies have shown that there is a link between dieting
and the development of eating disorders in teenagers.
Adolescent girls who diet are more likely to develop an
eating disorder than girls who do not diet.
4. Perinatal events: Perinatal adverse events (prematurity, small for gestational age, and cephalohematoma)
may increase the risk of developing anorexia nervosa.
Furthermore, young women with a past history of
anorexia nervosa may have an increased risk of experiencing adverse perinatal events.
5. Personality traits: The personalities of adolescents
with anorexia nervosa are characterized by perfectionism, anxiety, low self-esteem, and obsessionality.
6. Early puberty: There is a greater risk for developing an
eating disorder in girls who experience early puberty.
Puberty is a time for biological changes in body weight,
shape, and size with increased deposition of body
fat.
7. Chronic illness: Teenagers with chronic illness, such
as diabetes mellitus, are at greater risk for developing
an eating disorder.
8. Physical and sexual abuse: Research suggests that
adolescents who have been sexually abused have about
the same or only slightly higher incidence of anorexia
nervosa as those who have not been abused.
9. Family history/family psychopathology: There are elevated rates of psychiatric disorders (anxiety disorders
and affective disorders) in first-degree relatives of patients with anorexia nervosa.
10. Competitive athletics: Participation in certain sports
or activities that place a high emphasis on body weight
and appearance (e.g., ballet and gymnastics) put young
people at risk for anorexia nervosa.
Clinical Manifestations—Typical
Presentation
The common behaviors, signs, and symptoms associated
with adolescents with anorexia nervosa are outlined in the
subsequent text.
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Behaviors
1. Dieting: Dieting in young people may be the result of a
comment about body weight, shape, or size by a family
member, teacher, coach, physician, or peer. Young
people can often identify exactly when the dieting
began.
2. Relentless pursuit of thinness: Initially, weight loss
may be reinforced by positive comments from parents
or peers who admire the patient’s will power and sense
of control. Eventually, preoccupation with food, shape,
and weight progress and the patient loses control over
eating.
3. Distorted body image: The distortion of body image
and denial of feelings of hunger result in continued
weight loss, eventually leading to a state of emaciation.
4. Unusual eating attitudes and behaviors: Low-calorie
foods (e.g., salad with vinegar and no oil, diet foods,
and soft drinks) or foods low in fat are preferred.
Foods previously enjoyed by the adolescent with
anorexia nervosa are avoided. Adolescents with eating
disorders tend to eat the same foods at the same
time each day. Adolescents with anorexia nervosa may
break food into small portions, eat foods of the same
color, hide food, or secretly throw food away. Often
large amounts of water or diet sodas with caffeine
are consumed to satisfy hunger or to cause diuresis.
Many adolescents with anorexia nervosa enjoy reading
cookbooks, collecting recipes, watching cooking shows
on television, cooking, and preparing food for others,
although they themselves will not eat.
5. Increased physical activity: Some adolescents will
engage in increased physical activity as a means to
control their weight. They may stand constantly, move
their arms and legs, run up and down stairs, jog, do
floor exercises or calisthenics in an effort to expend
energy. As weight loss continues, activity level often
increases.
6. Purging behaviors: Some patients with anorexia nervosa purge to augment weight loss. Purging may take
the form of vomiting, diuresis, food restriction, excessive exercise, or the use of herbal remedies or
complementary and alternative medicines (CAM).
7. Frequent weighing: Adolescents with anorexia nervosa may weigh themselves daily or multiple times a
day. The weight on the scale often determines how the
adolescent feels about him or herself.
8. Wearing baggy clothes: Often adolescents with anorexia nervosa will wear baggy or layered clothing to
conceal their weight loss or because they are cold.
9. Poor self-esteem: Adolescents with anorexia nervosa
often have feelings of insecurity and helplessness when
dealing with people or certain situations. Many young
people will control their weight and eating habits in an
attempt to reduce these negative feelings.
10. Isolation: Young people with anorexia nervosa usually
withdraw from friends and family. This may reflect an
attempt to minimize contact with criticizing or teasing
peers. It is also a manifestation of low self-esteem and
impaired social skills. The teen with anorexia nervosa
tends to avoid social situations, as these circumstances
are often associated with food.
11. Inflexibility: There is a strong sense of ‘‘right and
wrong’’ to the point of not accepting individual
differences.
12. Irritability and mood changes: It is not uncommon
for parents to describe their adolescent with anorexia
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nervosa as moody or irritable. Starvation can cause
some of these changes in mood.
Signs and Symptoms
Signs and symptoms may be minimal but can include the
following:
1. Signs
a. Weight loss: Adolescence is a time of intense growth
and development. There is great variability in the
rate, timing, and magnitude of weight gain, changes in
height, and sexual maturation during normal puberty.
The diagnostic criteria for anorexia nervosa outlined
in the DSM-IV includes weight loss defined as refusal
to maintain body weight at or above a minimally
normal weight for age and height (e.g., weight loss
leading to maintenance of body weight <85% of that
expected or failure to make expected weight gain
during period of growth, leading to body weight
<85% of that expected). There are concerns about
this weight criterion, especially the threshold when
considering an adolescent underweight. Although
formalized diagnostic criteria can be helpful, it
is essential to consider the multiple and varied
aspects of normal pubertal growth and adolescent
development when diagnosing anorexia nervosa.
Therefore, any significant or unexpected weight
loss in an adolescent is cause for concern. The
signs of malnutrition include loss of subcutaneous
tissue, temporal wasting, loss of muscle mass, and
prominence of bony protuberances.
b. Amenorrhea: This is one of the diagnostic criteria
outlined in the DSM-IV for postmenarcheal females.
In 20% to 25% of patients with anorexia nervosa,
the amenorrhea precedes the weight loss; in approximately 50%, the amenorrhea occurs at about the
same time as the weight loss; and in approximately
25%, the amenorrhea occurs after substantial weight
loss. One study found that amenorrhea did not discriminate between women with anorexia nervosa and
those with all the features except amenorrhea across
a number of relevant variables. As such, the utility
of amenorrhea as a diagnostic criterion has been
questioned in the postmenarcheal female (Garfinkel
et al., 1996). Finally, an increasing number of patients are being seen with premenarcheal onset of
the disorder. Resumption of menses usually occurs
within 3 to 6 months of achieving goal weight when
normal hypothalamic-pituitary-ovarian function is restored (Golden et al., 1997).
c. Pubertal delay: Anorexia nervosa can delay the start
or progression of puberty in adolescents. An episode
of anorexia nervosa before or during pubertal development has the potential for long-term adverse effects
on sexual maturation (in particular breast development), menarche, or normal menstrual function. Early
treatment is critical to avoid delay or irreversible
effects on pubertal growth and development.
d. Lack of growth or poor growth: An adolescent who
develops anorexia nervosa before growth is complete
may develop growth retardation (Lantzouni et al.,
2002; Modan-Moses et al., 2003). It is important
to review the growth chart to determine whether
the patient has crossed growth percentiles. Lack of
growth or poor growth is more likely to occur in
males because of the longer growth period of males.
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e. Changes in body hair: Young people with anorexia
nervosa often develop lanugo hair, a fine downy hair
commonly seen on the back, stomach, or face. They
may also complain of hair loss or thinning.
f. Skin: The skin is often dry with hyperkeratotic areas.
There may be yellow or orange discoloration, most
noticeable on the palms of the hand. Nail changes
have been described in the form of pitting and ridging.
g. Recurrent fractures
h. Hypothermia: Decreased oral body temperature that
may be as low as 35◦ C.
i. Bradycardia: The most common cardiac finding.
j. Hypotension: Hypotension often associated with
significant postural changes can be observed in
adolescents with anorexia nervosa.
k. Acrocyanosis
l. Edema, usually dependent
m. Systolic murmur sometimes associated with mitral
valve prolapse
2. Symptoms
a. Cold intolerance: Young people with anorexia nervosa
may report that they feel cold when others around
them feel fine.
b. Postural dizziness and fainting
c. Early satiety, abdominal bloating, discomfort, and
pain.
d. Constipation (secondary to reduced fluid and dietary
intake and lack of response to the usual enteroceptive
cues to defecation).
e. Fatigue, muscle weakness, and cramps
f. Poor concentration
Laboratory Features
Laboratory findings in patients with anorexia nervosa can
include the following:
1. Hematological
a. Leukopenia: May be a relative lymphocytosis
b. Anemia: Not common and usually a late finding
c. Thrombocytopenia
d. Decreased serum complement C3 levels (but reference range levels of C4) and granulocyte killing defect;
no evidence for increased susceptibility to bacterial
infection
e. Decreased erythrocyte sedimentation rate (ESR
<4 mm/hour); if the ESR is elevated, consider another
diagnosis
2. Chemistry
a. Increased blood urea nitrogen (BUN) concentration
b. Mildly increased serum glutamic-oxaloacetic transaminase and serum glutamic-pyruvic transaminase
levels
c. Hypophosphatemia
d. Depressed serum magnesium and calcium concentrations
e. Increased cholesterol
f. Increased serum carotene level in 15% to 40% of
patients
g. Decreased vitamin A level
h. Decreased serum zinc and copper levels
3. Endocrine: The hormonal changes in anorexia nervosa
reflect an adaptive response to malnutrition.
a. Thyroid
• Thyrotropin (TSH): Within the reference range
CHAPTER
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AQ1
5.
6.
7.
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ANOREXIA
• Thyroxine (T4 ): Within the reference range or
slightly low
• 3,5,3 -Triiodothyronine (T3 ): Often low, probably
representing increased conversion of T4 to reverse
T3
• The thyroid changes represent adaptation to starvation, do not require thyroid hormone replacement, and will reverse with weight gain.
b. Growth hormone (GH):
• Decreased insulin-like growth factor 1 (IGF-1) levels
• GH levels normal or elevated
c. Prolactin: Reference range levels
d. Gonadotropins
• Basal levels of luteinizing hormone (LH) and folliclestimulating hormone (FSH): Usually low.
• Twenty-four-hour LH secretory pattern: Prepubertal with low LH levels and no spikes or occasional
nocturnal spikes
• FSH and LH response to gonadotropin-releasing
hormone (GnRH): Often a severely blunted response to GnRH, particularly if weight loss is severe
e. Sex steroids
• Estradiol: Low in females (<30 pg/mL)
• Testosterone: Low in males
f. Cortisol: Normal secretion on stimulation. Basal levels are within the reference range or occasionally
slightly high. A decreased response of adrenocorticotropic hormone (ACTH) to corticotropin-releasing
hormone has been noted. This resolves by 6 months
after weight gain has occurred. This abnormality of
ACTH response is not found in individuals with bulimia and normal weight.
Cardiac
a. Electrocardiogram (ECG): Bradycardia, low-voltage
changes, prolonged QTc interval, T-wave inversions,
and occasional ST-segment depression
b. Echocardiogram: Decreased cardiac size and left
ventricular wall thickness, increased prevalence of
mitral valve prolapse (Johnson et al., 1986), and
pericardial effusion.
Gastrointestinal (GI)
a. Upper GI tract series: Usually normal findings;
with occasional decreased gastric motility. May
demonstrate features of the superior mesenteric
artery syndrome.
b. Barium enema: Normal findings
Renal and metabolic
a. Decreased glomerular filtration rate
b. Elevated BUN concentration
c. Decreased maximum concentration ability (nephrogenic diabetes insipidus)
d. Metabolic alkalosis
e. Alkaline urine
Low bone mineral density (BMD) (osteopenia or osteoporosis)
Diagnosis and Differential Diagnosis
The diagnosis of anorexia nervosa should be suspected
in any adolescent with unexplained weight loss and food
avoidance. The diagnosis is based not only on the absence
of a defined organic cause but also on the presence
of certain characteristics. The most commonly used
diagnostic criteria for anorexia nervosa are outlined in the
American Psychiatric Association’s DSM-IV (Table 33.1).
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The differential diagnosis includes both medical and
psychiatric conditions:
1. Medical conditions
a. Inflammatory bowel disease
b. Malabsorption
c. Endocrine conditions—hyperthyroidism, Addison’s
disease, diabetes mellitus
d. Collagen vascular disease
e. Central nervous system (CNS) lesions—hypothalamic
or pituitary tumors
f. Malignancies
g. Chronic infections—tuberculosis, human immunodeficiency virus (HIV)
h. Immunodeficiency
2. Psychiatric conditions
a. Mood disorders
b. Anxiety disorders
c. Somatization disorder
d. Substance abuse disorder
e. Psychosis
Evaluation
The evaluation of the patient with a suspected eating disorder should include a comprehensive history and physical
examination and certain preliminary laboratory tests.
History
Helpful questions regarding eating, weight-control behavior, and other issues include:
1. Why has the teen and/or family come for an assessment?
2. How does the teen feel about the way she/he looks?
3. Is the teen trying to change the way she/he looks?
4. Has there been any change in the teen’s weight? If yes,
what methods has the teen used to control his or her
weight?
5. How much does the teen want to weigh?
6. Does the teen binge? Describe a ‘‘binge’’? How often
does the teen binge?
7. Are there any purging behaviors such as vomiting,
laxative abuse, diuretic use, ipecac use, diet pills, herbal
medications or other CAM?
8. What was the most and least the teen has weighed and
when was that?
9. Does the teen’s feelings about her/his body affect
her/his mood?
10. Is there any particular part of the teen’s body that he
or she is uncomfortable with and why (e.g., buttocks
or thighs)?
11. How much does the disordered eating interfere with
the teen’s life? How much time does he or she spend
preparing food, exercising, and weighing him or herself?
12. How much does the teen worry about eating or her/his
weight?
13. Exercise history? Type, amount, and frequency?
14. What has the teen eaten in the last 24 hours?
15. Has the teen ever had a menstrual period? If yes, when
was her last normal menstrual period? How often does
she get her period? Has there been any change in her
periods? Is the teen on oral contraceptive pill (OCP)?
16. Family medical and psychiatric history including teen
or other family members with an eating disorder,
mental illness, or substance abuse problem/disorder.
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17. Any prior or current history of sexual, physical, or
emotional abuse?
18. How does the family understand the teen’s eating
problem? What have the parent(s)/caregiver/family
members done to support the teen?
19. Where does the teen get help? With whom does he or
she share information?
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1.
2.
3.
4.
5.
Instruments
Several instruments have been developed to aid in the
diagnosis of eating disorders and the differentiation of
anorexia from bulimia nervosa. These include the following:
1. Eating Attitudes Test (EAT-26): This screening test
is a 26-item self-report questionnaire that examines
attitudes and behaviors regarding food, weight, and
body image. A score >21 is suggestive of an eating
disorder and warrants further evaluation (Garner and
Garfinkel, 1979).The EAT-26 has been validated for use
in adolescents.
2. Eating Disorders Inventory: A 91-item questionnaire that
can be used both for screening and monitoring the
emergence of an eating disorder in a high-risk group
but not for diagnosis. It assesses drive for thinness,
body dissatisfaction, bulimic behaviors as well as other
dimensions associated with eating disorders including
ineffectiveness, perfectionism, interpersonal distrust, interoceptive awareness, and maturity fears. Scores reflect
percentiles for normal populations (Garner et al., 1983).
3. Eating Disorders Examination Questionnaire (EDE-Q):
The EDE-Q (Fairburn and Beglin, 1994) is a 38-item
self-report version of the Eating Disorders Examination
administered to assess eating disorder pathology. The
questionnaire assesses restraint and concerns about
eating, body weight, and shape.
4. Kids’ Eating Disorders Survey (KEDS): The KEDS (Childress et al., 1993) is a 14-item self-report instrument
requiring a 2nd grade reading level. It includes a threepoint scale and eight figure drawings for assessing body
shape concerns. Normal values are available.
Physical Examination
The physical examination should focus on the signs
of malnutrition previously described. Height and weight
should be carefully measured and plotted on the Centers
for Disease Control and Prevention (CDC) growth charts.
Previous growth curves are very helpful. Abnormal growth
in weight and height may be an indication that there is a
medical problem, such as anorexia nervosa. Weight should
be measured in a hospital gown or light clothing after the
patient has emptied her bladder. Body mass index (BMI)
should be calculated (BMI = weight in kilograms divided
by height in meters squared) and plotted on the CDC
growth charts. The percentage of ideal or standard body
weight should be determined from the National Center
for Health Statistics Tables (the original data sets from
which the growth curves were drawn). For the adolescent,
these are readily available at www.Pocket-Doc.com. Finally,
sexual maturity rating (SMR) should be determined on each
adolescent in order to make sure that puberty is proceeding
in a predictable and normal manner.
Laboratory Assessment
Suggested laboratory tests are listed in the subsequent
text:
6.
7.
8.
9.
10.
11.
12.
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Complete blood cell (CBC) count and platelet count
ESR
BUN and serum creatinine
Urinalysis
Serum electrolytes and liver function tests: Hypokalemia with an increased serum bicarbonate level may
indicate frequent vomiting or use of diuretics, whereas
nonanion gap acidosis is common with laxative abuse.
Caloric restriction alone, without any purging behavior,
does not usually cause hypokalemia. Hyponatremia is
common and may be secondary to excess water intake.
Mild elevations of serum transaminases occur in 4% to
38% of patients with anorexia nervosa.
Serum calcium, phosphate, magnesium, and phosphorus concentrations
Serum albumin level (usually normal)
Carotene level
T3 , T4 , and TSH levels
LH, FSH, estradiol, and prolactin level if amenorrheic
ECG
BMD should be measured in females with anorexia
nervosa who have been amenorrheic for >6 months.
The most frequently used test is dual energy x-ray
absorptiometry (DXA).
Optional laboratory tests include:
1.
2.
3.
4.
Upper GI tract series and small bowel series
Barium enema
Celiac screen
Computed tomography or magnetic resonance imaging
(MRI) of the head
Nutritional Assessment
The nutritional assessment should include a 24-hour
dietary recall, an assessment of both foods and beverages
consumed, and anthropometric measurements such as
height, weight, BMI, and skinfold measures. A 24-hour
recall, including portion sizes and the types of food
products used can highlight whether the diet is sufficient,
balanced, and structured. Adolescents should be asked
to describe which foods they consume from each food
group. Adolescents with eating disorders may consume
a large quantity of diet products and avoid entire food
categories such as fats, carbohydrates, or protein. They
may also drink an excessive amount of fluids including
caffeinated products such as coffee, tea, iced tea, or soda
to reduce hunger and alter body weight. An assessment of
dietary calcium intake should be made. Adolescents require
1200 to 1500 mg of calcium/day and may require calcium
supplementation should their dietary calcium intake fall
below their requirements.
Treatment
1. Team approach: Treatment is best conducted by an
interdisciplinary team of individuals who are skilled and
knowledgeable in working with adolescents with eating
disorders and their families. The treatment team typically consists of a physician, therapist, and nutritionist.
It is critical that there is excellent communication among
the members of the team and that information is shared
as appropriate.
2. Diagnosis: The most critical step in treating anorexia
nervosa is to recognize and address the eating disorder
as soon as possible. It is important to inform the
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adolescent and the family of the diagnosis and treatment
plan.
3. Medical and nutritional intervention: The goals of medical intervention are nutritional rehabilitation, weight
restoration, and reversal of the acute medical complications. Once there is improvement in the physiological
symptoms of starvation, psychological treatment can
begin.
4. Psychological intervention: Psychotherapy is an important component of the treatment of adolescents with
anorexia nervosa. For the adolescent to be involved in a
psychotherapeutic treatment program, he or she needs
to be motivated to some extent. The psychological therapies currently used for the treatment of anorexia nervosa
include family psychoeducation, interpersonal therapy,
and family therapy. Recently, family-based treatment
has been found to be effective in the adolescent agegroup (Le Grange et al., 2003). It is also important to
remember that teens with eating disorders may suffer
from a coexisting mental illness such as an anxiety disorder or depression and this needs to be considered in
making treatment recommendations.
5. Pharmacological treatment: Some adolescents with eating disorders may benefit from the use of psychotropic
medications. Fluoxetine does not appear to be effective
in treating the primary symptoms of anorexia nervosa (Attia et al., 1998). Other studies have explored
the efficacy of medication after weight restoration, with
differing results. One study reported that fluoxetine
prevented relapse in older adolescents with anorexia
nervosa who have attained 85% of their expected body
weight (Kaye et al., 2001), whereas a recent study
failed to demonstrate any benefit from fluoxetine in
weight restored patients with anorexia nervosa (Walsh
et al., 2006). The most common medications used have
TABLE
NERVOSA
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BULIMIA
NERVOSA
483
included the SSRIs such as: fluoxetine, sertraline, paroxetine, fluvoxamine, and citalopram. These medications
are also useful in treating comorbid depression or OCD.
Health care providers need to be aware that the U.S.
Food and Drug Administration has required manufacturers of these medications to include a ‘‘black box’’
warning label that alerts health care providers and consumers to an increased risk of suicidal thinking and
behavior in adolescents being treated with the medications (Lock et al., 2005). In addition, there are some
recent reports that the atypical neuroleptic medications
such as risperidone, olanzapine, and quetiapine may be
effective in adolescents with anorexia nervosa. Case reports and small cohort studies have shown that these
medications have been helpful in reducing anxiety and
obsessional thinking and enhancing weight gain. Further research is required to understand the benefits of
these medications in the treatment of anorexia nervosa
in adolescents.
6. Treatment setting: The actual treatment setting for the
adolescent with anorexia nervosa may involve inpatient
treatment, outpatient treatment, partial hospitalization,
or residential treatment. Indications for hospitalization
are outlined in Table 33.2 (Golden et al., 2003).The goals
of hospitalization should be weight gain and reversal
of the acute medical complications such as electrolyte
disturbances and vital sign instability. Attempts should
be made to achieve weight gain through the oral
route, if possible. Short-term nasogastric feeding may be
necessary in those with severe malnutrition. Behavioral
contracts have been helpful and are used in most
inpatient programs. Nutritional rehabilitation needs
to be performed slowly to prevent the ‘‘refeeding
syndrome’’—a constellation of cardiac, hematological,
and neurological symptoms associated with refeeding a
33.2
Indications for Hospitalization in an Adolescent with an Eating Disorder
One or more of the following justify hospitalization:
1. Severe malnutrition (weight ≤75% average body weight for age, sex, and height)
2. Dehydration
3. Electrolyte disturbances (hypokalemia, hyponatremia, hypophosphatemia)
4. Cardiac dysrhythmia
5. Physiological instability
Severe bradycardia (heart rate <50 beats/min daytime; <45 beats/min at night)
Hypotension (<80/50 mm Hg)
Hypothermia (body temperature <96◦ F)
Orthostatic changes in pulse (>20 beats/min) or blood pressure (>10 mm Hg)
6. Arrested growth and development
7. Failure of outpatient treatment
8. Acute food refusal
9. Uncontrollable binging and purging
10. Acute medical complications of malnutrition (e.g., syncope, seizures, cardiac failure, pancreatitis)
11. Acute psychiatric emergencies (e.g., suicidal ideation, acute psychosis)
12. Comorbid diagnosis that interferes with the treatment of the eating disorder (e.g., severe depression,
obsessive-compulsive disorder, severe family dysfunction)
Reprinted with permission from Golden NH, Katzman DK, Kreipe RE, et al. Eating disorders in adolescents. Position paper of the
Society for Adolescent Medicine. J Adolesc Health 2003;33:496.
484
PA R T
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CONDITIONS
AFFECTING
Cerebral
ventricular
enlargement
Metabolic
recovery
Weight
restoration
NUTRITION
Eating
habits
AND
Gray
matter
brain
changes
Osteopenia
Resumption
of menses
WEIGHT
FIGURE 33.2 Timeline for
resolution of the medical
complications of anorexia nervosa.
(Reprinted with permission from
Golden NH, Meyer W. Nutritional
rehabilitation of anorexia nervosa.
Goals and dangers. Int J Adolesc Med
Health 2004;16(2):131. Freund
Publishing House Ltd.)
Vital sign
instability
Electrolyte
disturbances
Days
Weeks
Months
malnourished patient. The most serious feature of this
syndrome is sudden unexpected death associated with
hypophosphatemia and cardiac arrhythmias. A weight
gain of 2 to 3 lb a week is optimal. Most, but not
all, of the medical complications are reversible with
nutritional rehabilitation (Golden and Meyer, 2004).
Those conditions that may not be reversible include
growth retardation, osteopenia, and structural brain
changes (Katzman, 2005). A timeline for resolution of
the medical complications of anorexia nervosa is shown
in Figure 33.2.
7. Advice for parents or other caretakers: Several suggestions may be helpful in advising parents who have
teenagers with an eating disorder. These include the
following:
a. Be patient: The recovery from anorexia nervosa is a
long and hard process. There is no quick or easy cure.
The recovery often takes 5 to 6 years.
b. Avoid blaming: It is helpful for family members to
avoid blaming themselves or others for the cause of
the eating disorder.
c. Avoid comments: Avoid comments about your adolescent’s weight and appearance. This is often perceived as criticism. Also, avoid comments about your
own weight and appearance and the weight and
appearance of others. Focus on traits that are not
appearance-related.
d. Promote a positive body image and healthy attitude
toward eating and activity.
e. Encourage family meals as often as reasonably
possible.
f. Avoid making food the struggle. Food often becomes
the central topic of discussions and arguments.
Parents often become concerned and frustrated when
their adolescent refuses to eat. As the adolescent
loses weight, it becomes more difficult to change the
adolescent’s eating attitudes and behaviors.
g. Work with your health care team. The health
care team consists of skilled professionals who
can treat the adolescent with the eating disorder
and support the family through the course of the
illness.
Years
Complications
1. Fluid and electrolytes related
a. Dehydration
b. Hypokalemia
c. Hyponatremia
d. Hypophosphatemia
e. Hypomagnesemia
f. Hypoglycemia
2. Cardiovascular
a. Sinus bradycardia; sinus arrhythmia
b. Orthostatic hypotension
c. Ventricular dysrhythmias
d. Reduced myocardial contractility
e. Sudden death, secondary to arrhythmias
f. Cardiomyopathy secondary to ipecac use
g. Mitral valve prolapse
h. ECG abnormalities including low voltage, prolonged
QTc interval, and prominent U waves
i. Pericardial effusion
j. Congestive heart failure
3. Renal
a. Increased BUN
b. Decreased glomerular filtration rate
c. Renal calculi
d. Edema
e. Renal concentrating defect
4. GI
a. Delayed gastric emptying
b. Constipation
c. Elevated liver enzymes (acute fatty necrosis)
d. Superior mesenteric artery syndrome
e. Rectal prolapse
f. Gallstones
5. Hematological
a. Anemia
b. Leukopenia
c. Thrombocytopenia
6. Endocrine or metabolic
a. Primary or secondary amenorrhea
b. Pubertal delay
c. Thrombocytopenia
CHAPTER
33
ANOREXIA
d. Euthyroid sick syndrome (Low T3 syndrome)
e. Hypercortisolism
f. Decreased serum testosterone level
g. Partial diabetes insipidus
h. Elevated cholesterol level
7. Osteopenia
a. Fractures: Females with anorexia nervosa have reduced bone mass (osteopenia) and increased fracture risk (Golden et al., 2003). Osteopenia at one
or more sites occurs in approximately 90% of patients who meet DSM-IV criteria for anorexia nervosa (Golden et al., 2002; Grinspoon et al., 2000)
and the degree of osteopenia is more severe than
that seen in hypothalamic amenorrhea (Grinspoon
et al., 1999). Body weight is the most important
determinant of BMD and weight gain is associated
with an increase in BMD (Bachrach et al., 1991), although levels may not revert to normal. Hormone
replacement therapy has not been proven to be effective in increasing BMD in adults (Klibanski et al.,
1995) or in adolescents (Golden et al., 2002). Recent studies have demonstrated a positive effect
of treatment with IGF-1 (Grinspoon et al., 2002),
dehydroepiandrosterone (Gordon et al., 2002), and
bisphosphonates (Golden et al., 2005) although these
modalities are still being studied and are not yet
recommended for general use. Current recommendations include weight restoration and resumption of
spontaneous menses, calcium, and vitamin D supplementation and moderate weight-bearing exercise.
8. Neuromuscular
a. Generalized muscle weakness
b. Seizures secondary to metabolic abnormalities
c. Peripheral neuropathies
d. Cardiomyopathy secondary to ipecac abuse
e. Syncope in absence of orthostatic hypotension
f. Movement disorders
g. Structural brain changes—MRI studies have demonstrated enlargement of the lateral ventricles and sulci
and significant deficits in both gray- and white-matter
volumes in the low-weight stages. Increases in sulcal
volume and decreases in gray-matter volume may not
be fully reversible with weight recovery.
Clinical and Laboratory Findings Associated
with Sudden Death
a.
b.
c.
d.
e.
Prolonged QTc interval
Decreased serum phosphate concentration
Ipecac cardiomyopathy
Severe emaciation (<70% of ideal body weight)
Suicide
Outcome
More than 100 studies have been conducted on the outcome
of anorexia nervosa over the last 50 years with wide
variability in the results. Comparisons among studies are
limited by differences in definitions of ‘‘cases,’’ length
of follow-up, and type of data collected (Fisher, 2003).
General consensus is that the prognosis for adolescents
with anorexia nervosa is better than that for adults, due in
part to the shorter duration of symptoms in adolescents.
Approximately 50% of adolescents have a ‘‘good’’ outcome,
approximately 30% have a ‘‘fair’’ outcome, and 20% a
‘‘poor’’ outcome.
NERVOSA
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485
In a well-designed prospective study, 95 adolescents
with anorexia nervosa (ages 12–17) were followed up at 6- to
12-month intervals for 10 to 15 years (Strober et al., 1997).
There was full recovery in 75.8%, partial recovery in an
additional 10.5%, and chronicity or no recovery in 13.7%.
However, the time to full recovery was prolonged and
ranged from 57 to 79 months. Readmission to the hospital
within the first year of treatment occurred in 30% of patients
but did not portend a poor prognosis. Adolescents with
anorexia nervosa can fully recover, but the time to recover
may take many years and the path may be difficult. The
following are some of the findings pertaining to recovery:
1. Weight restoration: At follow-up, 22% to 79% were of
normal weight, 15% to 43% were 11% to 21% below
normal, 2% to 10% were overweight.
2. Menses: Sixty-five percent to 95% of patients with
anorexia nervosa were menstruating at follow-up.
3. Eating difficulties: Only a third of subjects were eating
normally at follow-up (Hsu, 1980); 23% to 67% had
restricted food intake, 11% to 50% were still vomiting
or abusing laxatives.
4. Psychological disturbances: Psychiatric comorbidity
was common in follow-up studies. Important findings
include a lifetime incidence of depression in 50% to 68%;
anxiety disorders (especially OCD and social phobia)
in 30% to 65%; substance abuse in 12% to 21%; and
comorbid personality disorders in 20% to 80%. Estimates
of good or satisfactory psychosocial functioning ranged
from 22% to 73%. Approximately one third of patients
with anorexia nervosa develop bulimia nervosa.
5. Psychosocial: Most patients were engaged in full-time
employment, with good work attendance.
6. Mortality: The mortality rate ranges from 2% to 8%
with longer-term studies revealing a mortality as high
as 15% (Ratnasuria et al., 1991). Patients with anorexia
nervosa are 12 times more likely to die than women of a
similar age in the general population (Keel et al., 2003).
The most common causes of death are suicide and the
medical complications of starvation.
Certain factors seem to relate to a good prognosis or
poor prognosis:
1. Good prognosis
a. Short duration of illness
b. Early identification and intervention
c. Early onset (<14 years old)
d. No associated comorbid psychological diagnoses
e. No binging and purging
f. Supportive family
2. Poor prognosis
a. Longer duration of illness
b. Binging and purging
c. Comorbid mental illness (affective disorder, substance abuse)
d. Lower body weight at diagnosis
Anorexia nervosa appears to have lower recovery rates
than bulimia nervosa. Weight restoration and resumption
of menses seem to respond well to treatment. Psychological
improvements also occur but take much longer.
BULIMIA NERVOSA
Bulimia nervosa is an eating disorder characterized
by binge eating coupled with compensatory behaviors
486
PA R T
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CONDITIONS
AFFECTING
intended to promote weight loss such as self-induced
vomiting, laxative abuse, excessive exercise, or prolonged
fasting. The profound emaciation associated with anorexia
nervosa is not present in adolescents with bulimia nervosa, and most individuals have a normal weight. Menses
are usually normal but may be irregular. The adolescent
with bulimia nervosa is usually quite aware of the abnormal eating attitudes and behaviors and is quite distressed
by them. The DSM-IV diagnostic criteria for bulimia nervosa are listed in Table 33.3. Adolescents who meet the
criteria for anorexia nervosa but also binge or purge are
classified as anorexia nervosa, binge eating/purging type.
Approximately one third of patients with anorexia nervosa
‘‘cross over’’ to bulimia nervosa at some time in their
illness.
Epidemiology
1. Prevalence: Large-scale studies from several countries
have found that up to 15% of adolescents report binge
eating or purging behaviors (Schneider, 2003). The numbers are even higher for college students. Zuckerman
et al. (1986) found that 23% of college women and 14% of
college men reported binging at least once each week,
and 23% of the females and 9% of the males used vomiting, laxatives, or diuretics for weight control. However,
most of these young people do not meet DSM-IV criteria
for bulimia nervosa. The lifetime prevalence of bulimia
nervosa in young females living in western industrialized
countries is estimated to be 1% to 4%.
2. Age: Onset is usually during late adolescence or early
adulthood with a modal age at onset of 18 to 19 years
old. Bulimia nervosa developing in patients younger than
14 years is rare.
3. Gender: Ninety percent to 95% are female, although
recently there has been a reported increased prevalence
in males, particularly in those who must weight qualify
for interscholastic events (e.g., wrestlers).
TABLE
NUTRITION
AND
WEIGHT
4. Comorbidity: Approximately 80% of patients with bulimia nervosa report a lifetime prevalence of another
psychiatric condition (Fichter and Quadfling, 1997).
The major comorbid conditions are affective disorders (50%–80%), anxiety disorders (13%–65%), personality disorders (20%–80%), and substance abuse
(25%) (Walsh et al., 2005). Patients with bulimia nervosa
tend to be more impulsive than those with anorexia
nervosa and may engage in shoplifting, stealing, selfdestructive acts, and sexual acting out.
Risk Factors
As for anorexia nervosa, risk factors for bulimia nervosa
are not a direct cause of the disease, but increase the
likelihood of developing the condition.
1. Age and gender: Bulimia nervosa is more likely to
develop during adolescence. Females are more likely
to be affected than males.
2. Early childhood eating and health problems: Some studies have shown that early childhood eating problems
(pica, early digestive problems, and weight reduction
efforts) are associated with the later development of
bulimia nervosa.
3. Weight concerns, negative body image, and dieting:
Body dissatisfaction, perceived pressure to be thin, and
dieting have all been identified as risk factors for the
development of bulimic symptoms.
4. Personality traits: Negative affect, impulsivity, stressful
life events, and family conflict have been associated with
increased risk of developing bulimia nervosa.
5. Early puberty: Some studies have shown that early
menarche increases the risk of developing bulimia.
6. Family history: As for anorexia nervosa, there is an
increased risk of developing bulimia nervosa if a family
member has an eating disorder. Concordance rates are
higher for monozygotic than for dizygotic twins and
33.3
DSM-IV Diagnostic Criteria for Bulimia Nervosa
1. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
a. Eating, in a discreet period of time (e.g., within any 2 hour period), an amount of food that is definitely larger
than most people would eat during a similar period of time and under similar circumstances.
b. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control
what or how much one is eating).
2. Recurrent inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting; misuse of
laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.
3. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a wk for 3 mo.
4. Self-evaluation is unduly influenced by body shape and weight.
5. The disturbance does not occur exclusively during episodes of anorexia nervosa.
Two types have been identified:
1. Purging type: During the current episode of bulimia nervosa, the person has regularly engaged in self-induced
vomiting or the misuse of laxatives, diuretics, or enemas.
2. Nonpurging type: During the current episode of bulimia nervosa, the person has used other inappropriate
compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced
vomiting or the misuse of laxatives, diuretics, or enemas.
Reprinted with permission from the American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed.
Text Revision, Copyright, 2000.
CHAPTER
33
ANOREXIA
range from 27% to 83%. A susceptibility locus for bulimia
nervosa has been identified on chromosome 10p (Bulik
et al., 2003).
7. Childhood sexual abuse: Childhood sexual abuse is
sometimes associated with the later development of
bulimia nervosa (Wonderlich et al., 2001).
Clinical Manifestations—Typical
Presentation
The common behaviors, signs, and symptoms associated
with adolescents with bulimia nervosa are outlined in the
subsequent text.
Behaviors
1. Binging and purging: The most important behaviors in
adolescents with bulimia nervosa are the binging and
purging. The binge episode is the rapid consumption of
a large amount of high calorie food in a short period of
time and associated with self-perceived loss of control
over eating. The most common triggers for binge
eating include negative mood, interpersonal stress,
hunger due to dietary restriction, and negative feeling
related to one’s body image. The individual often
experiences feelings of being ‘‘out of control’’ during
the binge episode. Binging occurs after a short period
of starvation, typically in the afternoon after having
skipped breakfast or lunch, or late in the evening.
Binges can be enormously large in caloric content
(as high as 3,000–5,000 kcal). After a binge, feelings
of guilt and shame together with fear of weight gain
result in purging. Methods of purging include vomiting,
excessively exercising, fasting for a day or days after
a binge, taking laxatives, diuretics, ipecac, diet pills,
herbal remedies, or CAM. The binging and purging
is often done secretly. Purging may initially have a
calming effect and relieve guilt over a binge episode.
This may lead to recurrent cycles of binging and
purging in an attempt to manage feelings of depression
and anxiety.
Initially, the binge–purge activity may be infrequent, but with time, it may increase to daily or even
several times a day. In addition, as the condition progresses, some individuals with bulimia nervosa will
purge even after ingesting normal or small amounts
of any food that might be considered high in calories
or fat. Therefore, over time, what began as a diet or
weight-control measure turns into a means of mood
regulation with the binging and purging behaviors becoming a source of coping.
2. Evidence of purging: Some adolescents will make frequent trips to the bathroom, particularly after eating. In
addition, there may be signs and/or smells of vomit, presence of empty food containers, or packages of laxatives
or diuretics.
3. Evidence of binge eating: Often family members of adolescents with bulimia nervosa report the disappearance
of food or the presence of empty wrappers and containers indicating the consumption of large amounts of food.
In addition, adolescents with bulimia nervosa may steal,
hoard, or hide food, and eat in secret.
4. Frequently weighing self
5. Preoccupation with food
6. Overly concerned with food, body weight, shape, and
size.
NERVOSA
AND
BULIMIA
NERVOSA
487
Signs and Symptoms
Signs and symptoms may be minimal but can include the
following:
1. Signs
a. Body weight is usually normal or above normal.
b. Skin changes: Calluses on the dorsum of the hand
secondary to abrasions from the central incisors
when the fingers are used to induce vomiting. This
physical sign is known as Russell sign’s.
c. Enlargement of the salivary glands, particularly the
parotid glands; usually bilateral and painless.
d. Dental enamel erosion (perimolysis): Usually occurs
in the lingual, palatal, and posterior occlusal surfaces
of the teeth.
e. Weight fluctuations.
f. Edema (fluid retention).
2. Symptoms
a. Weakness and fatigue
b. Headaches
c. Abdominal fullness and bloating
d. Nausea
e. Irregular menses
f. Muscle cramps
g. Chest pain and heartburn
h. Easy bruising (from hypokalemia/platelet dysfunction)
i. Bloody diarrhea (in laxative abusers)
Table 33.4 contrasts anorexia nervosa with bulimia
nervosa.
Diagnosis and Differential Diagnosis
The most commonly used diagnostic criteria used for
the diagnosis of bulimia nervosa are outlined in the
American Psychiatric Association’s DSM-IV (Table 33.3).
The differential diagnosis includes both medical and
psychiatric conditions:
1. Medical conditions
a. Chronic cholecystitis
b. Cholelithiasis
c. Peptic ulcer disease
d. Gastroesophageal reflux disease
e. Superior mesenteric artery syndrome
f. Malignancies (including CNS tumors)
g. Infections—acute bacterial and viral GI infections,
parasitic infections, and hepatitis
h. Pregnancy
i. Oral contraceptives: Nausea can be a side effect of oral
contraceptives and hormone replacement therapy
j. Medications—some medications have side effects
that may include nausea and vomiting, or food
cravings
2. Psychiatric conditions
a. Anorexia nervosa-binge/purge subtype
b. Binge eating disorder
c. Major depressive disorder, with atypical features
d. Borderline personality disorder
e. Kleine-Levin syndrome
Evaluation
Evaluation includes a complete history and physical
examination.
488
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AFFECTING
NUTRITION
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WEIGHT
33.4
Anorexia Nervosa versus Bulimia Nervosa: Similar and Contrasting Features
Area
Anorexia Nervosa
Bulimia Nervosa
Epidemiology
90% Female patients
Increased prevalence of eating disorders and
depression in families
Onset early to midadolescence
Prevalence <1%
Intense fear of gaining weight or becoming fat
Introverted, obsessional, perfectionistic, rigid
Same
Same
Psychopathology
Poor self-esteem
Secretive about behaviors
Binge eating not necessary
Level of denial high
Physical signs
Weight
Menses
Underweight; must be <85% expected weight
Must be amenorrheic
Laboratory screening includes:
1. CBC count
2. BUN and creatinine, electrolytes, glucose, calcium, phosphorus
3. Serum amylase
4. ECG with rhythm strip
5. Urinalysis—specific gravity
Treatment
Like adolescents with anorexia nervosa, the treatment of
young people with bulimia nervosa requires an interdisciplinary team approach. The first step is to make a diagnosis
and address the eating disorder as soon as possible. The
principles of treatment include the following:
1. Medical and nutritional intervention: The goals of
medical intervention include careful medical monitoring
and the correction of any medical complication, in
particular electrolyte abnormalities. A structured meal
plan developed with the help of a nutritionist can be very
helpful. Eating three normal meals a day will reduce
the physiological drive to binge in the late afternoon
or evening. The adolescent should be encouraged and
supported to avoid foods that trigger a binge (e.g., ice
cream or baked goods). Promoting moderate exercise
can also be helpful. Adolescents should have routine
dental care and consultation should be sought for those
teens with dental damage secondary to vomiting.
2. Psychological intervention: In adults, multiple studies
have shown that cognitive-behavioral therapy (CBT) reduces binge eating and purging activity in approximately
30% to 50% of patients. Attitudes about body shape and
weight are also improved. Treatment with CBT is time
limited and problem oriented. It focuses on strategies
to cope with the emotional triggers that lead to binge
eating and purging and addresses ways to modify abnormal attitudes to eating, body shape, and weight. In
Slightly older onset
Prevalence 1%–4%
Same
More outgoing, impulsive, prone to acting-out
behaviors (shoplifting, sexual promiscuity,
self-destructive acts)
Same
Same
Binge eating must be present
Aware of problem; wants help
Usually of normal weight
Weight can be normal, high, or low
May have normal, irregular, or absent menses
individuals with bulimia nervosa, treatment with CBT
has been found to be more effective than other psychological treatments such as supportive psychotherapy,
interpersonal therapy, or stress management (Walsh
et al., 2005).
3. Pharmacologic treatment:
Multiple studies have
demonstrated a positive effect of a number of different
antidepressants for treating bulimia nervosa. The SSRIs
are better tolerated and have fewer side effects than earlier generations of antidepressants. Fluoxetine is the only
medication approved by the FDA for the treatment of
bulimia nervosa and is most effective at a dose of 60 mg
daily (Fluoxetine Bulimia Nervosa Collaborative Study
Group, 1992; Walsh et al., 1997). Treatment with fluoxetine results in a decrease in binge-eating and purging
episodes in 55% to 65% of subjects. A combination of antidepressant medication and CBT appears to be superior
to either modality alone (Nakash-Eisikovits et al., 2002).
4. Treatment settings: The treatment settings for adolescents with bulimia nervosa are similar to those outlined
for anorexia nervosa. The majority of adolescents with
bulimia nervosa can be treated in an outpatient setting
(outpatient clinic or partial hospitalization).
Complications
1. Fluid and electrolytes related
a. Dehydration
b. Hypokalemia (the most frequently seen electrolyte
abnormality—either from vomiting or from laxative
or diuretic use)
c. Hyponatremia
d. Hypophosphatemia (especially when binging occurs
after a prolonged period of dietary restriction)
2. Cardiovascular
a. Cardiac arrhythmias
b. Ipecac cardiomyopathy
CHAPTER
33
ANOREXIA
3. GI
a. Parotid gland enlargement and increased serum
amylase levels
b. Esophagitis
c. Mallory-Weiss tears
d. Rupture of the esophagus or stomach
e. Acute pancreatitis
f. Paralytic ileus secondary to laxative abuse
g. Cathartic colon
h. Barrett Esophagus
4. Pulmonary
a. Aspiration pneumonia secondary to vomiting
b. Pneumomediastinum secondary to vomiting
5. Dental
a. Erosion of dental enamel
b. Dental caries
Outcome
Most adolescents with bulimia nervosa recover over
time with recovery rates ranging from 35% to 75% at
5 years of follow-up (Fichter and Quadfling, 1997). Bulimia
nervosa tends to be a chronic relapsing condition and
approximately one third of patients relapse in 1 to 2 years.
Comorbidity is frequent but mortality is low.
In one study, after a 90-month follow-up period, the
full recovery rate in women with bulimia nervosa (74%)
was significantly higher than that of women with anorexia
nervosa (33%) (Herzog et al., 1999). No predictors of
recovery emerged among bulimic subjects. Eighty-three
percent of women with anorexia nervosa and 99% of
those with bulimia nervosa achieved partial recovery.
Approximately one third of both groups relapsed after
full recovery. No predictors of relapse emerged. Bulimia
nervosa was characterized by higher rates of both partial
and full recovery.
NERVOSA
AND
BULIMIA
NERVOSA
489
4. Teens who purge daily but never binge
5. Adolescents who repeatedly chew and spit out but do
not swallow their food
6. Individuals who binge-eat but do not purge (see Binge
Eating Disorder)
An alternative classification for the range of eating
disorders of childhood and younger adolescents is outlined
in the Great Ormond Street (GOS) criteria (Lask and BryantWaugh, 1993; Nicholls et al., 2000). The diagnoses within
this classification not only consist of anorexia nervosa and
bulimia nervosa but also include the following diagnostic
categories:
1. Food avoidance emotional disorder (FAED): FAED
refers to a condition seen in children 8 to 13 years
old where the child refuses to eat. There is no fear of
becoming fat and no distortion in body image. This condition may be accompanied by growth retardation and
weight loss.
2. Selective eating disorder (SED): SED refers to those
younger patients who will limit their foods to one or two
foods for a prolonged period of time. They are unwilling
to try new foods, which can be a major source of frustration for their parents. Similar to those with FAED, they do
not have the cognitive distortions regarding weight or
shape. Their weight and height are usually appropriate
for age.
3. Functional dysphagia: Functional dysphagia refers to
children and younger adolescents who will avoid certain foods because of a fear of swallowing, choking,
or vomiting. Often there is a history of an episode of
choking on a specific food.
4. Pervasive food refusal: Pervasive food refusal refers to
children and younger adolescents who have a profound
refusal to eat, drink, walk, and talk or self-care and are
resistant to efforts to help.
The overriding similarities among these diagnostic
criteria are the lack of abnormal cognitions and morbid
preoccupation with weight and shape.
EATING DISORDERS NOT OTHERWISE
SPECIFIED
EDNOS refers to the diagnostic category of patients who
have problems with eating or body image but who do
not meet full DSM-IV criteria for either anorexia nervosa
or bulimia nervosa. This category accounts for most
adolescents presenting for treatment (Fisher et al., 2001;
Nicholls et al., 2000). Importantly, these adolescents suffer
from the same medical complications and similar degree of
psychological distress as those who meet full criteria. Some
of the individuals in the EDNOS category represent those
with subthreshold anorexia nervosa or bulimia nervosa,
but others represent qualitatively distinct disorders. This
heterogeneous diagnostic category is likely to undergo
further refinement in the near future.
Examples of individuals with EDNOS include:
1. Teens with all the criteria for anorexia nervosa but who
have regular menses
2. Individuals who appear to have anorexia nervosa, but
despite significant weight loss, their present weight is in
the normal range
3. Individuals who meet all the criteria for bulimia nervosa
except that the frequency of binging or purging is less
than twice a week or lasts for <3 months
BINGE EATING DISORDER
Binge eating disorder is a newly recognized disorder and
only recently appeared in the DSM-IV (1994) under the
category of EDNOS and is also listed as a category for
proposed diagnoses and further research. The DSM-IV
proposed criteria include the following:
1. Recurrent episodes of binge eating. An episode of binge
eating is characterized by both of the following:
a. Eating, in a discrete period of time (e.g., within any
2-hour period), an amount of food that is definitely
larger than what most people would eat during a
similar period and under similar circumstances
b. A sense of lack of control over eating during the
episode (e.g., a feeling that one cannot stop eating or
control what or how much one is eating)
2. The binge eating episodes are associated with three or
more of the following:
a. Eating more rapidly than normal
b. Eating until feeling uncomfortably full
c. Eating large amounts of food when not physically
hungry
d. Eating alone because of embarrassment
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AFFECTING
NUTRITION
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e. Feeling disgusted with self and depressed
3. Marked distress regarding binge eating is present.
4. The binge eating occurs, on an average, at least 2 days a
week for 6 months.
5. The binge eating is not associated with the regular use
of inappropriate compensatory behaviors (e.g., purging,
fasting, and excessive exercise) and does not occur
exclusively during the course of anorexia nervosa or
bulimia nervosa.
2. Struggling with sexual identity conflict
3. Diagnosed with comorbid mental disorders
4. With a family history of an eating disorder
This type of eating pattern can lead to significant
weight problems and obesity. Some of these individuals
start these behaviors after a period of weight-loss diets
and restrictive eating, whereas others use the binge as a
calming mechanism unrelated to prior dietary restrictions.
Because it is only a recently recognized disorder, there
is very little research on binge eating disorder in this
age-group. Community-based surveys suggest that binge
eating disorder occurs in 1% to 2% of adolescents between
the ages of 10 to 19 (Johnson et al., 1999; Zaider et al.,
2000; Johnson et al., 2002). Most people with binge eating
disorder are obese, but normal-weight people can also
be affected (Schneider, 2003). Epidemiological studies in
children and adolescents have shown that more boys
report having binges than girls (19%–33% of boys versus
6%–7% of girls) (Whitaker et al., 1989; Childress et al., 1993);
however, when the symptom of loss of control is included
in the definition of binging, more girls than boys report
binging (25.6% versus 12.5%) (Croll et al., 2002). Up to 20%
of individuals who present with treatment for obesity meet
the criteria for binge eating disorder. In contrast to anorexia
nervosa and bulimia nervosa, binge eating disorder affects a
more diverse population including more male and nonwhite
individuals.
The causes of binge eating disorder are still unknown.
Up to half of all people with binge eating disorder have a
history of depression. The impact of dieting on binge eating
disorder is also unclear.
The major complications of binge eating disorder are
the complications that are often associated with obesity.
Obese adolescents with binge eating disorder are at higher
risk for poor self-esteem and depression.
Most young people with binge eating disorder are
extremely distressed by their binge eating. Those who
try to control the binge eating are not successful over
the long term. Treatment approaches currently being
studied include CBT, interpersonal psychotherapy, and
psychotropic medications such as antidepressants.
FEMALE ATHLETE TRIAD
MALES AND EATING DISORDERS
Approximately 10% of older adolescents suffering from eating disorders are male. The percentage of males with eating
disorders is higher in young adolescent males than in adult
males. The reasons for the growing prevalence in younger
adolescent males remains unclear. Research indicates that
eating disorders in adolescent males are clinically similar to
eating disorders in females. Body image concerns appear
to be one of the strongest variables in predicting eating
disorders in males. Adolescent males at increased risk for
developing an eating disorder include those:
1. Involved in athletic activities where there is a focus on
body weight and body image—body builders, wrestlers,
dancers, swimmers, runners, rowers, gymnasts, and
jockeys
Although males of all types of sexual orientation
develop eating disorders, several studies report that there
is an increased incidence of homosexuality among males
with eating disorders.
The female athlete triad is a syndrome consisting of disordered eating, amenorrhea, and osteoporosis in female
athletes. The key feature is that in these athletes, caloric intake is insufficient for energy expenditure. The resulting
‘‘energy deficit’’ causes hypothalamic amenorrhea (primary or secondary) and a low estrogen state. The low
estrogen state is associated with osteoporosis and increased fracture risk.
Females at greatest risk are those participating in sports
that emphasize a lean physique (e.g., figure skating, gymnastics, ballet, long distance running, and swimming). The
triad is not restricted to elite athletes but is also seen
with increasing frequency in recreational athletes. Frequent
weigh-ins, consequences for weight gain, and pressure
from parents or athletic coaches may also increase an
athlete’s risk.
Many female athletes with the triad do not meet the
strict DSM-IV criteria for anorexia nervosa or bulimia
nervosa, but engage in similar disordered eating behaviors
such as dietary restriction, prolonged fasting, self-induced
vomiting, or the use of laxatives, diuretics, or diet pills to
lose weight or maintain a thin physique. Body weight can
be low, but often is in the normal range and usually there
is no body image distortion.
This disorder often goes unrecognized because of the
subtlety of the symptoms, the secretive nature of the
disorder, and the belief that amenorrhea is a common
consequence of athletic training. The exact prevalence
of the female athlete triad is unknown. The prevalence
of disordered eating behavior in female college athletes
ranges between 15% and 62%. In addition, the prevalence
of amenorrhea is between 3.4% and 66% among female
athletes, compared to 2% to 5% in the general population.
Early recognition of the female athlete triad is important
and therefore requires careful screening and assessment.
Every female athlete with amenorrhea should have a complete history and physical examination to evaluate for an
underlying eating disorder and to rule out other treatable causes of amenorrhea. Principles of treatment include
increasing caloric intake, calcium and vitamin D supplementation, restricting the intensity of training (if necessary),
and monitoring for resumption of menses. Adolescent
athletes, their parents, and coaches should be educated
about this disorder and the associated health risks.
WEB SITES
For Teenagers and Parents
http://www.cswd.org/. Council on Size and Weight Discrimination Web site attempts to change public opinion and
policy regarding weight issues.
CHAPTER
33
ANOREXIA
http://www.anad.org/. The National Association of Anorexia
Nervosa and Associated Disorders operates an international network of support groups for patients and families
and offers referrals to health care professionals who treat
eating disorders across the United States and in 15 other
countries.
http://www.edreferral.com/anorexia nervosa.htm. Eating
disorder referral and information center of the International Eating Disorder Referral Organization.
http://www.aacap.org/about/glossary/anorexia.htm. The
American Academy of Child and Adolescent Psychiatry.
http://www.mentalhealth.com/book/p45-eat1.html.
Information from the National Institute of Mental
Health.
http://www.somethingfishy.org. The Something Fishy Web
site on eating disorders has resources of all kinds,
including information and online support.
For Health Professionals
http://www.aedweb.org. The Academy for Eating Disorders
Web site that promotes effective treatment.
http://www.edap.org/. The National Eating Disorders Association (NEDA) is a nonprofit organization in the United
States working to prevent eating disorders and provide
treatment referrals to those suffering from anorexia, bulimia, and binge eating disorder and those concerned
with body image and weight issues.
http://www.adolescenthealth.org/Eating Disorders in
Adolescents.pdf.
The
Society
for
Adolescent
Medicine (SAM) position paper on adolescent eating
disorders.
http://www.nationaleatingdisorders.org. The National Eating Disorders Association (NEDA) Web site offers information about eating disorders and body image; referrals
to treatment centers, doctors, therapists, and support
groups; opportunities to get involved in prevention efforts; prevention programs for all ages; and educational
materials.
http://www.anred.com. Anorexia Nervosa and Related Eating Disorders Inc. (ANRED) is a nonprofit organization
that provides information about eating disorders. The
material includes self-help tips and information about
recovery and prevention.
http://www.iaedp.com. International Association of Eating
Disorder Professionals’ mission is to promote a high level
of professionalism among practitioners who treat those
suffering from eating disorders by emphasizing ethical
and professional standards.
http://www.psych.org/psych pract/treatg/pg/eating
revisebook index.cfm. Practice guidelines for patients
with eating disorders from the American Psychiatric Association–second edition, 2000.
http://www.mentalhealth.com/book/p45-eat1.html.
Information from National Institute of Mental
Health.
http://www.Pocket-Doc.com/IBW.htm. A palm pilot-based
program to calculate ideal body weight based on age and
height using the NCHS charts. It also calculates BMI and
plots BMI on the new CDC charts.
http://www.nedic.ca. The National Eating Disorder Information Centre (NEDIC) is a Canadian organization that
provides information and resources on eating disorders
and weight preoccupation.
NERVOSA
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BULIMIA
NERVOSA
491
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Queries in Chapter 33
AQ1. Please provide the reference details for Johnson.
AQ2. Please check this correction.