Clinical Vignette

Ellen W. had gained 15 pounds during her freshman year at college and felt out of control. She began a strict diet, limiting her intake to 1000 calories daily. She also began to run every day. By summer’s end she had returned to her baseline weight but decided to continue her diet and exercise regime. She was continually hungry and sometimes binged, but she soon discovered how to induce vomiting and settled into a regular pattern of bingeing and purging. After another year, she came to medical attention when she was brought—against her objections—to an emergency room after collapsing while running.

On examination she was cachectic, hypotensive, and bradycardic. Her teeth were eroded and she had parotid enlargement. Laboratory studies revealed microcytic anemia, metabolic alkalosis, and hypokalemia. She was admitted and eventually required forced feeding to correct her life-threatening nutritional deficiencies. Throughout her hospitalization, she insisted that she was well but slightly overweight and needed to lose 10 more pounds. Five years later, she participated in regular individual and family psychotherapy. She had stopped bingeing and had negotiated a slightly less rigorous diet with her therapists, but she continued to monitor her caloric intake and weight every day.

Ellen W. suffers from anorexia nervosa, one of the two main eating disorders described in Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition (the other is bulimia). Anorexia nervosa is characterized by distorted body image, an unwillingness to maintain normal weight, emaciation, amenorrhea, and severely disordered eating habits. Anorexia nervosa is one of the deadliest of psychiatric disorders—a recent estimate is that 6% of anorectics die from their illness.

Anorexia

Anorexia and other eating disorders are primarily diseases of young women. Its cause is unknown, but anorectic patients typically display high levels of anxiety and perfectionism, and twin studies suggest comorbidity with major depression and a substantial inherited risk (Fig. 27-1). However, unlike many other psychiatric illnesses, the prevalence of anorexia varies among different cultures; pressure to conform to cultural standards of thinness may play an important role in initiating the disorder.

Figure 27-1 Eating Disorders.

The best treatment for anorexia is unclear, but there is general agreement that no progress can be made until the patient is restored to a safe weight. Zinc supplementation may be particularly important. Patients usually receive intensive individual and sometimes family psychotherapy. No medication is clearly effective.

Bulimia

Bulimia, the other major eating disorder, is characterized by recurrent episodes of excessive food intake and loss of control, preoccupation with weight and body image, and inappropriate compensatory behaviors to control weight, such as fasting, excessive exercise, induced vomiting, and ingestion of laxatives and diuretics. Unlike anorectics, bulimic patients are usually obese or of normal weight.

Bulimia is less deadly than anorexia but much more common. The prevalence is especially high in settings where thinness is demanded, such as modeling, professional dance, and some athletics. There is a high rate of comorbidity with depression.

Bulimia is responsive to psychotherapy that includes education in healthy eating and weight management and a cognitive approach that addresses the all-or-none thinking that leads to binges.

Most antidepressant medications are at least partially effective in treating bulimia (the exception is bupropion, which is contraindicated in eating disorder patients because of a heightened risk of seizures). Selective serotonin reuptake inhibitors are considered first-line treatment. The anticonvulsant topiramate also appears to have a clinically useful antibingeing effect.