Evidence-Based Reviews

Update on eating disorders Anorexia nervosa: Dual therapy can bring patients back from the brink

Current Psychiatry. 2004 March;3(3):39-59

References

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2. Bruch AH. Eating disorders: obesity, anorexia nervosa, and the person within. New York, Basic books, 1973.

3. Kleifield E, Wagner S, Halmi KA. Cognitive behavioral treatment of anorexia nervosa. Psychiatr Clin North Am 1996;19:715-34.

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6. Braun DL, Sunday SR, Halmi KA. Psychiatric comorbidity in patients with eating disorders. Psychol Med 1994;24:859-67.

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9. Baran S, Weltzin T, Kaye W. Low discharge weight and outcome in anorexia nervosa. Am J Psychiatry 1995;150:1070-2.

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11. Howard W, Evans K, Quinter-Howard C, et al. Predictors of success or failure of transition to day hospital treatment for inpatients with anorexia nervosa. Am J Psychiatry 1999;156:1697-1702.

12. Wiseman C, Sunday SR, Klapper F, et al. Changing patterns of hospitalization in eating disorder patients. Int J Eat Disord 2001;30:69-74.

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In college, she began abusing alcohol and was arrested once for driving while intoxicated.

Depression is the most common comorbidity in anorexia nervosa. Two-thirds of anorectic patients in a 10-year follow-up study reported a history of major depressive disorder.⁵ Suicide, starvation, and electrolyte imbalance are the three major causes of death. Among severely ill patients who require hospitalization, 10% to 20% die, though the suicide rate is undocumented.

Compulsions. Anorectics’ preoccupations about food and eating rituals have been compared with compulsions, though less than 20% of patients meet diagnostic criteria for obsessive-compulsive disorder.⁶

Substance abuse. Bulimic anorectics report more alcohol and substance use and abuse than restricting anorectics.⁷ The most common substances of abuse are cannabis, cocaine, stimulants, and over-the-counter pills such as diet aids.

Personality disorders. Up to 50% of patients with anorexia nervosa—particularly the binge/purge subtype—have personality disorders. Borderline personality disorder is especially common among binge/purge types,⁸ and avoidant personality disorder is more common among restricting types.

Table 3

Diagnostic signs of emaciation and purging in patients with anorexia nervosa

Emaciation Dry, cracking skin Lanugo hair Bradycardia Hypotension Leukopenia with relative lymphocytosis Anemia Hypercholesterolemia Reduced bone density
Purging Calluses on dorsum of hand, produced by hand friction from self-induced vomiting Perioral dermatitis Enlarged parotid glands (“chipmunk” face) Tooth enamel erosion, caries, periodontitis Cardiac arrhythmias (hypokalemia from purging) Hypochloremic metabolic alkalosis Hyperamylasemia QT interval and T-wave changes on ECG

Personality disorders usually reflect instability in interpersonal relationships, poor self-image, or fluctuating affect. Patients may show a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.

Sexuality. Psychosocial and sexual development is often delayed in adolescent anorectics. In adults, interest in sex often plummets with anorexia onset, although binge/purge-type patients occasionally become promiscuous.

Medical signs

Case report continued: Abnormal ECG.

Ms. J was hospitalized after her weight dropped below 75% of normal for her age, height, and body build. She showed signs of electrolyte disturbance, including severe bradycardia (pulse rate 40) and ST-segment abnormalities on ECG.

Clinical signs of emaciation and purging can assist with diagnosis and in making decisions about medical treatment, including hospitalization (Table 3). Patients who purge are often weak and have puffy cheeks or parotid gland enlargement. They may have fainting spells and scars on their hands from stimulating vomiting. Laxative abuse may decrease colon motility and worsen constipation.

Neuroendocrine changes secondary to dieting and weight loss include:

increased corticotropin-releasing hormone secretion
blunted diurnal cortisol fluctuation
decreased follicle-stimulating hormone (FSH) secretion
impaired growth hormone regulation
decreased luteinizing hormone (LH) secretion
mildly decreased triiodothyronine
erratic vasopressin secretion.

Measuring these changes is unnecessary, as general nutritional rehabilitation with weight gain will correct them.

Neurotransmitter function. Emaciated anorectics have a blunted response to pharmacologic probes for dopamine, reduced CSF norepinephrine turnover, and decreased CSF serotonin. Neuroimaging studies suggest that serotonin dysfunction may persist after weight is restored, although these findings require replication.

Treatment priorities

Effective therapies. Open studies indicate that multidimensional treatment—medical management, psychoeducation, and individual cognitive-behavioral therapy (CBT)—is most effective for anorexia nervosa. The fewer than 10 controlled trials that address anorexia nervosa treatment show:

the more severe the illness, the more intense the treatment required
outpatient therapy is most successful in patients who have had the illness <6 months, are not binging and vomiting, and have parents who participate in family therapy.

Hospitalization. An emaciated patient who is irritable, depressed, preoccupied with food, and sleep-deprived is unlikely to make progress toward behavioral change. The first goal, therefore, is to restore her nutritional state to normal.

Severely ill anorectic patients require hospitalization for daily monitoring of weight, calorie intake, urine output, and serum electrolytes and amylase (to assess purging behavior). Hospitalization is indicated for:

loss of >20% of normal weight for age, height, and bone structure
>6 months of repeated hospitalizations and underweight
psychotic depression or serious suicide attempt
incapacitating obsessions and compulsions, related or not to the eating disorder
serious comorbid medical conditions, such as edema, hypoproteinemia, severe anemia, cardiac arrhythmia, or hypokalemic alkalosis (serum K+ < 2.5 mEq/L).

Keeping a patient in the hospital long enough to provide effective medical and psychological therapy has become difficult, however, because of medical insurance restrictions (Box). The result: poorer outcomes and increased relapse rates compared with 10 years ago.^9-12

Box

Shorter hospitalizations, worse outcomes for patients with eating disorders

Hospital treatment of eating disorders has shifted from long-term care of a chronic disorder to stabilization of acute episodes. For some patients, this change has been deleterious and not cost-effective.

A decade ago, eating disorder hospitalizations were covered primarily by private insurance. Today, health maintenance organizations, managed care oversight of private insurance, and public funding are the primary sources of payment. These insurers often limit payment for eating disorder hospitalization, the most costly aspect of psychiatric care.

Poor outcomes and a high relapse rate have been documented in anorexia nervosa patients who left the hospital while underweight.^9-11 From 1984 to 1998:

average hospital stays for anorexia nervosa decreased from 150 days to 23.7 days
readmissions increased from 0% to 27% of total admissions
anorectic patients’ average body mass index at discharge dropped from 19.3 to 17.7, a statistically significant difference.¹²

For psychiatrists, this trend means many outpatients with anorexia nervosa will require repeated hospitalizations that will not substantially improve their anorectic behaviors.