Evidence-Based Reviews

Are undiagnosed eating disorders keeping your patients sick?

Current Psychiatry. 2005 December;4(12):65-75

References

1. Reas Dl, Williamson DA, Martin CK, Zucker NL. Duration of illness predicts outcome for bulimia nervosa: a long-term outcome study. Int J Eat Disord 2000;27:428-34.

2. Nielsen S, Moller-Madsen S, Isager T, et al. Standardized mortality in eating disorders—a quantitative summary of previously published and new evidence. J Psychosom Res 1998;44:413-34.

3. Hoek HW, van Hoeken D. Review of the prevalence and incidence of eating disorders. Int J Eat Disord 2003;34(4):383-96.

4. Watson TL, Andersen AE. A critical examination of the amenorrhea and weight criteria for diagnosing anorexia nervosa. Acta Psychiatr Scand 2003;108:175-82.

5. Milos G, Spindler A, Schnyder U. Psychiatric comorbidity and eating disorder inventory (EDI) profiles in eating disorder patients. Can J Psychiatry 2004;49:179-84.

6. Rubenstein CS, Pigott TA, L’ Heureux F, et al. A preliminary investigation of the lifetime prevalence of anorexia and bulimia nervosa in patients with obsessive compulsive disorder. J Clin Psychiatry 1992;53(9):309-14.

7. Becker CB, DeViva JC, Zayfert C. Eating disorder symptoms among female anxiety disorder patients in clinical practice: the importance of anxiety comorbidity assessment. J Anxiety Disord 2004;18(3):255-74.

8. Keys A, Brozek J, Henschel A, et al. The biology of human starvation. Minneapolis: University of Minnesota Press; 1950.

9. Ramacciotti CE, Dell’Osso L, Paoli RA, et al. Characteristics of eating disorder patients without a drive for thinness. Int J Eat Disord 2002;32:206-12.

10. Andersen AE. Males with eating disorders: medical considerations. In: Mehler PS, Andersen AE (eds). Eating disorders: a guide to medical care and complications. Baltimore: The Johns Hopkins University Press; 1999;214-26.

11. Lantzouni E, Frank GR, Golden NH, Shenker RI. Reversibility of growth stunting in early onset anorexia nervosa: a prospective study. J Adolesc Health 2002;31(2):162-5.

12. Napolitano MA, Head S, Babyak MA, Blumenthal JA. Binge eating disorder and night eating syndrome: psychological and behavioral characteristics. Int J Eating Disord 2001;30:193-203.

13. Jacobi C, Morris L, de Zwaan M. Overview of risk factors for anorexia nervosa, bulimia nervosa, and binge eating disorder. In: Brewerton, TD (ed). Clinical handbook of eating disorders: An integrated approach. New York: Marcel Dekker; 2004;183-208.

14. Fairburn CG, Beglin SJ. Assessment of eating disorders: interview or self-report questionnaire. Int J Eating Disord 1994;16:363-70.

15. Garner DM. Eating Disorder Inventory-2 professional manual. Odessa, FL: Psychological Assessment Resources; 1991.

16. Garner DM. Psychoeducational principles in treatment. In: Garner DM, Garfinkel PE (eds). Handbook of treatment for eating disorders (2nd ed). New York: Guilford Press; 1997;145-77.

17. Miller KK, Grinspoon SK, Ciampa J, et al. Medical findings in outpatients with anorexia nervosa. Arch Intern Med 2005;165(5):561-6.

Identifying eating disorders

Screening. No formal guidelines recommend which psychiatric patients to screen for eating disorders. We suggest screening any patients who are over- or underweight or have eating disorder risk factors, such as:

young women (teens and early 20s)
athletes in certain sports (gymnastics, ballet, figure skating, running, body building, wrestling)
history of childhood sexual abuse.¹³

Suggested questions include, “How do you feel about your weight?” and “Do you ever binge eat?” If responses suggest an eating disorder, interview thoroughly while being sensitive to patients’ shame and ambivalence.

Interviewing. Evaluate all 4 illness domains—nutritional, medical, psychological, and social. Because patients often do not volunteer information, ask about:

symptoms and complications
onset and development of eating and weight problems
history of being teased or criticized about weight
weight history (premorbid, lowest, highest, and preferred weights).

Bingeing and purging. If the patient acknowledges bingeing, ask about its onset, frequency, triggers, and consequences. Obesity is common in patients who binge, but a person can meet diagnostic criteria for binge eating disorder without being obese.

DSM-IV-TR defines binging as consuming a large quantity of food in a discrete time and feeling out of control of eating. Ask specifically how the patient defines “binge,” and seek details of a typical binge. Also ask about compensatory behaviors (purging by vomiting or using laxatives or diuretics). Is the patient abusing ipecac, diet pills, or thyroid hormone? Does he or she fast or exercise compulsively (such as even while ill)?

Eating and exercise patterns. Ask the patient to recall everything eaten in the past 24 hours. This history can help estimate caloric intake and may reveal problematic eating patterns. For example, does the patient:

avoid certain foods, consider others to be “safe,” or use diet products, gum, or mints?
engage in food rituals, such as slow eating, hoarding food, or eating odd combinations?
steal food, weigh him/herself frequently, or visit pro-anorexia/pro-bulimia Web sites?

Complications. Ask the patient to describe the effect of eating disorder behaviors on relationships with family and friends and whether significant others also have eating or weight problems. Inquire about physical symptoms (Table 2) and psychological experiences such as preoccupation with food and impaired concentration.

Table 2

Potential medical complications of anorexia and bulimia nervosa

Organ system	Symptoms	Signs, syndromes, laboratory abnormalities
Cardiovascular	Palpitations, dyspnea, chest pain, dizziness	Bradycardia, orthostasis, acrocyanosis
Cardiovascular	Palpitations, dyspnea, chest pain, dizziness	Prolonged PR and QTc intervals on ECG, mitral valve prolapse, cardiomyopathy in ipecac abusers
CNS	Anxious, depressed, or irritable mood; obsessiveness; cognitive deficits; seizures (rare)	Enlarged ventricles on CT or MRI, deficits on neuropsychological testing, abnormal EEG, signs of peripheral neuropathy
Dermatologic	Hair loss, dry skin	Xerosis, carotenoderma, cheilitis, lanugo, brittle hair and nails, Russell’s sign (callus on dorsum of hand used to induce vomiting)
Endocrine	Fatigue, cold intolerance	Hypothermia, hypoglycemia, hypercortisolemia, ↓ T3 and T4
Gastrointestinal	Bloating, constipation, spontaneous vomiting, reflux, abdominal pain, heartburn, hematemesis	Abnormal bowel sounds, delayed gastric emptying, superior mesenteric artery syndrome, pancreatitis
Gastrointestinal		In patients who vomit: Mallory-Weiss tears, Barrett’s esophagus, occult blood in stool, ↑ amylase, gingivitis, dental caries, sialadenosis, perimolysis
Genitourinary	Polyuria, oliguria	↑ BUN, nephrolithiasis, hypokalemic nephropathy, renal failure (rare).
Hematologic	Fatigue, bruising	Anemia; ↓ numbers of WBCs, RBCs and platelets; ↓ ferritin, B12, folate
Metabolic	Weakness, cardiac or CNS manifestations	↓ K, Na, Mg, phosphate; ↑ cholesterol; metabolic alkalosis (from vomiting), or acidosis (from laxatives); thiamin and niacin deficiencies (rare).
Musculoskeletal	Weakness, cramps, bone pain	Wasting, ↑ CK (rare), decreased bone mineral density, pathologic fractures
Reproductive	Amenorrhea, ↓ libido, infertility, ↑ pregnancy, neonatal complications	Arrested sexual development; ↓ estrogen or testosterone; prepubertal levels of LH and FSH

Past treatment. Has the patient been treated for an eating disorder or attempted to change his or her behavior without seeking treatment? What worked, what didn’t, and why? To recover, what does the patient think he or she needs?

Interview adjuncts

Assessment tools. In addition to patient interviews, some clinicians use self-report scales to screen for eating disorders or to monitor treatment. Reliable and valid self-report questionnaires include the Eating Disorder Examination-Q (36 items),¹⁴ Eating Disorder Inventory (91 items),¹⁵ and Eating Attitudes Test (26 items).¹⁶

The Eating Attitudes Test takes 10 minutes to complete and is widely used for screening. A cut-off score of 20 indicates a potential eating disorder and the need for a follow-up interview.

Self-report diaries can help identify binge eating triggers—usually dietary restriction combined with interpersonal stressors. Ask the patient to record all meals, snacks, binges, purges, and exercise activities, plus time of day and associated feelings, thoughts, and situations. Diaries can also reveal maladaptive thoughts, such as body image distortion, and problematic coping strategies, such as purging or excessive exercising.

Medical workup

Measure height and weight, calculate body mass index, and check vital signs (including supine and standing blood pressure and pulse) and hydration status. Perform a neurologic exam, particularly for peripheral neuropathy, and check for cardiac, dermatologic, and GI complications (Tables 2 and 3). Include a dental examination if the patient admits or you suspect self-induced vomiting.