Eating Disorders: Anorexia Nervosa and Bulimia

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Chapter 23 Eating Disorders: Anorexia Nervosa and Bulimia

INTRODUCTION

Description: Anorexia nervosa is a syndrome characterized by an altered body image, significant weight loss, and amenorrhea that are not caused by physical disease. Bulimia is an eating disorder characterized by an altered body image and recurrent binge eating, with or without purging through self-induced vomiting, laxative abuse, or diuretics. Exercise excess is often a part of after-binge behavior. Both affect more women than men.
Prevalence: Females, 1% to 3%. Subclinical eating disorders are common in university populations.
Predominant Age: Teens to early 20s.
Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Unknown (emotional).
Risk Factors: Anorexia nervosa—perfectionistic personality (high expectations, personal or external). Bulimia—impulsive character, low self-esteem, stress (e.g., multiple responsibilities, tight schedules), early puberty. At high risk for both: dancers, models, cheerleaders, athletes.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Insidious onset (occasionally stress related)
• Significant weight loss (15% below expected weight)
• Denial of problem
• Preoccupation with weight or body image
• Anorexia nervosa—impression of obesity rather than objective view of weight

• Reduced food intake or refusal (often associated with elaborate eating rituals)
• Excessive exercise (marathon running)

• Bulimia—high-calorie binges followed by severe restriction

• Food collections or hoarding
• Medication abuse (laxatives, diuretics, ipecac, thyroid medication)
• Dental erosion and scarred knuckles (secondary to finger-induced vomiting)

DIAGNOSTIC APPROACH

Differential Diagnosis

• Wasting disease (tumors)
• Depression
• Hypothalamic tumor
• Food phobia
• Gastrointestinal disease
• Other emotional disorders (conversion disorder, schizophrenia, body dysmorphic disorder)

Associated Conditions: Major depression (50% to 75% of patients), obsessive-compulsive disorders (10% to 13% of patients), bipolar disorders, sexual disinterest, depression, growth arrest, hypotension and bradycardia, hypothermia, peripheral edema. Prolonged amenorrhea is associated with an increased risk of osteoporosis, which may not be reversible. Bulimia—social phobia and anxiety disorders, substance abuse, shoplifting common.

Workup and Evaluation

Laboratory: No evaluation specific for anorexia. For patients with bulimia there may be laboratory changes consistent with repeated vomiting (hypokalemia, hypomagnesemia, or hypochloremia).
Imaging: No imaging indicated.
Special Tests: Assessment of body fat.
Diagnostic Procedures: History and physical examination, Eating Attitudes Test.

Pathologic Findings

Anorexia nervosa—dry, cracked skin; sparse scalp hair; fine lanugo hair on extremities, face, and trunk; arrested maturation; pathologic fractures; cognitive defects. Bulimia—eroded dental enamel, esophagitis, Mallory-Weiss tears, parotid enlargement, gastric dilation.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Psychological evaluation and support, supervised eating and exercise program, progressive increase in calories and activity as weight is regained (anorexia), limit access to bathroom for 2 hours after eating (bulimia).
Specific Measures: Hospitalization may be required, including intensive psychological assessment and therapy. Tube feedings and intravenous fluids may be required for patients with anorexia.
Diet: Supervised program of reeducation and behavior modification. For patients with anorexia, a gradual increase in caloric intake as part of a supervised program of reeducation and behavior modification.
Activity: Stepwise increase based on weight change, avoidance of goal-oriented activities.
Patient Education: Nutritional instruction, assistance with a food log; American College of Obstetricians and Gynecologists Patient Education Pamphlet AP144 (Eating Disorders), AP064 (Weight Control: Eating Right and Keeping Fit), AP045 (Exercise and Fitness: A Guide for Women).

Drug(s) of Choice

Fluoxetine (Prozac) 10 to 60 mg PO daily.
Oxazepam 15 mg or alprazolam 0.25 mg PO before meals to reduce anxiety about weight gain.
Contraindications: See specific agents.

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Precautions: Starved patients tend to be more sensitive to medications or to have compromised renal, cardiac, or liver function.

Alternative Drugs

Imipramine (Tofranil) 10 mg gradually increased to 200 mg or desipramine (Norpramin) 25 mg increased gradually to 150 mg PO daily.
Lithium (Eskalith) 300 mg PO bid increased gradually until blood level of 0.6 to 1.2 mEq/L if bipolar disorder is present.
Cisapride (Propulsid) 10 to 20 mg before meals to increase gastric emptying.
Psyllium (Metamucil) 1 tablespoon every night to prevent constipation.

FOLLOW-UP

Patient Monitoring: Periodic weight measurements (weekly until stable, then monthly). Monitor for depression or suicidal ideation.
Prevention/Avoidance: Encourage healthy attitudes about weight, eating, and exercise; enhance self-esteem; and reduce stress.
Possible Complications: Drug and alcohol use/abuse, suicide, cardiac arrhythmia or arrest (potassium depletion), cardiomyopathy, suicide, necrotizing colitis, osteoporosis and osteoporotic fractures. Depression is common.
Expected Outcome: Highly variable with relapses common, better outcome with inpatient care. Bulimia may spontaneously remit.

MISCELLANEOUS

Pregnancy Considerations: Amenorrhea and infertility common in women with anorexia. For women with bulimia, the binge–purge cycle may affect fetal nutrition and growth when the behavior persists during pregnancy.
ICD-9-CM Codes: 307.1 (Anorexia), 783.6 (Bulimia).

REFERENCES

Level II

Centers for Disease Control and Prevention. Results from the National Adolescent Student Health Survey. MMWR Morb Mortal Wkly Rep. 1989;38:147.

Kurtzman FD, Yager J, Landvesk J, et al. Eating disorders among selected female student populations at UCLA. J Am Diet Assoc. 1989;89:45.

Legroux-Gerot I, Vignau J, Collier F, Cortet B. Bone loss associated with anorexia nervosa. Joint Bone Spine. 2005;72:489.

Signorini A, De Filippo E, Panico S, et al. Long-term mortality in anorexia nervosa: a report after an 8-year follow-up and a review of the most recent literature. Eur J Clin Nutr. 2007;61:119. Epub 2006 Aug 2

Level III

Abrams SA, Silber TJ, Esteban NV, et al. Mineral balance and bone turnover in adolescents with anorexia nervosa. J Pediatr. 1993;123:326.

Brunet M2nd. Female athlete triad. Clin Sports Med. 2005;24:623. ix.

Bruni V, Filicetti MF, Pontello V. Open issues in anorexia nervosa: prevention and therapy of bone loss. Ann N Y Acad Sci. 2006;1092:91.

Chamay-Weber C, Narring F, Michaud PA. Partial eating disorders among adolescents: a review. J Adolesc Health. 2005;37:417.

Crow SJ, Mitchell JE. Rational therapy in eating disorders. Drugs. 1994;48:372.

ESHRE Capri Workshop Group. Nutrition and reproduction in women. Hum Reprod Update. 2006;12:193. Epub 2006 Jan 31

Franko DL, Keel PK. Suicidality in eating disorders: occurrence, correlates, and clinical implications. Clin Psychol Rev. 2006;26:769. Epub 2006 Jul 27

Hay PJ, Bacaltchuk J Bulimia nervosa Clin Evid 14 2005 1170

Hay PJ, Bacaltchuk J Bulimia nervosa Clin Evid 15 2006 1315

Lentz GM. Emotional aspects of gynecology: sexual dysfunction, eating disorders, substance abuse, depression, grief, loss. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, editors. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby/Elsevier; 2007:179.

Morris J, Twaddle S. Anorexia nervosa. BMJ. 2007;334(7599):894.

Nattiv A, Agostini R, Drinkwater B, Yeager KK. The female athlete triad. The inter-relatedness of disordered eating, amenorrhea, and osteoporosis. Clin Sports Med. 1994;13:405.

Warren MP, Vande Wiele RL. Clinical and metabolic features of anorexia nervosa. Am J Obstet Gynecol. 1973;117:435.

Yager J, Andersen AE. Clinical practice. Anorexia nervosa. N Engl J Med. 2005;353:1481.

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