Perspectives in Eating Disorders

Adair Look, MD

“Emily,” a twenty-year-old college student, came to treatment just after having attempted suicide by overdosing on old pain medications she found in her parents’ bathroom. She admitted that, before the attempt, she had become despondent over her unstoppable need to chew large quantities of food and spit it out without ever swallowing any of it. She was wasting away, now carrying only eighty pounds on her five-foot, five-inch frame. Emily had been chewing and spitting out her food as a way to soothe herself since the sixth grade but had never been able to tell anyone because she was too embarrassed. “Who ever heard of something so gross? I couldn’t tell anyone!” she stated.

Emily is one of approximately five million people in the United States who suffer from an eating disorder, while many more suffer from disordered eating that borders on a full-fledged disorder. In addition, eating disorders carry the highest mortality risk of any psychiatric illness. Patients often come to treatment for reasons seemingly unrelated to their eating disorders. Although there is overlap in symptomotology, eating disorders are currently categorized into three distinct diagnoses: anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS). Many patients, like Emily, do not fit neatly into these categories. 

“Sarah” was forty-two when she presented to her internist with a concern for chronic halitosis. After an exhaustive medical workup, Sarah finally admitted to regurgitating her food two to three times per day. After her divorce ten years prior, she began regurgitating her food from stress. She welcomed its soothing effect and the fact that it made her weight easier to manage, so she continued the behavior despite its inconvenience and its effect on her breath. Sarah’s eating disorder, rumination, is far more prevalent than most treaters are aware. Kjelsas shows in his 2004 article that 3% of young women have AN, 8% have BN, and about 14% meet criteria for EDNOS. O’Brien (1995) and Fairburn (1984) showed that 17% to 33% of patients with BN engage in rumination at some time in their history.

Regardless of the commonality of the presenting symptoms, the immediate concerns in treating eating-disordered patients include refeeding syndrome, metabolic abnormalities, and cardiac abnormalities. Refeeding syndrome occurs when underweight patients have starved themselves to the extent that their cardiac tissue has atrophied, and when they are given increased fluids and solids, their cardiac capacity becomes overloaded. This results in dependent edema, tachycardia, increased jugular venous pressure, and cardiac rhythm abnormalities.

Metabolic abnormalities can in fact help diagnose eating disorders, as seen with “Kay.” Kay, a thirty-year-old woman, presented with low body weight, a low potassium and high CO2, though she denied vomiting to decrease caloric intake. A salivary amylase was drawn and proved elevated, indicating repeated vomiting. Once confronted with the results, Kay was able to admit to purging up to twelve times per day. 

Less immediate but equally damaging effects of eating disorders are exemplified by “Alyssa,” a twenty-seven-year-old woman with an eating disorder. Since age twelve, Alyssa has restricted calories and excessively exercised. During her first year of law school, her weight decreased to 92% of her ideal body weight (twenty pounds under normal weight for her), and she sustained a femoral neck fracture. She was able to normalize her weight over the next two years, but she then began excessively exercising again and fractured the metatarsals in her left foot. She suffers from female athletic triad: disordered eating, amenorrhea, and osteoporosis. Three to 66% of female athletes are affected, according to Yeager (1993).

The amenorrhea is hypothalamic in nature. During extreme stress, whether physiologic or psychiatric, the hypothalamic-pituitary-adrenal axis is activated to stop unnecessary bodily functions, resulting in cessation of reproductive function. It is intended to be a “protective mechanism” of the body, a reaction to stress. In fact, increase in stress causes increase in amenorrhea in 100%   of prisoners prior to execution, as found by Chrousos (1998). In 2005, Abraham showed that amenorrhea is also found in 24% of patients with EDNOS and 15% of patients with bulimia.

Osteoporosis, the third aspect of female athletic triad, commonly leads to bone fractures, as seen in the femoral neck fracture Alyssa sustained. Anorexic patients often cite the fact that weight-bearing exercise leads to increase in bone density. However, excessive weight-bearing exercise leads to decrease in bone mineral density, and osteoporosis often persists after weight restoration occurs and hormonal levels normalize.

Mood disorders are common in eating-disordered patients, with comorbid Axis I diagnoses in 73% of patients with AN and in 60% of patients with BN (Herzog 1992). Recent research has focused on the connection between eating disorders and mood, showing that serotonin is involved in modulating impulsivity, obsessionality, mood, and appetite. Patients with bulimia show a decrease in naturally occurring serotonin and a decrease reactivity to serotonin. Patients with anorexia also show a decrease in serotonin activity and reactivity, but these levels increase after weight recovery has been achieved. "Pamela" was unable to keep her weight above one hundred pounds, despite being five foot, nine inches tall. She was also profoundly depressed and often contemplated suicide. She was eventually able to increase her body weight because her psychopharmacologist explained that SSRIs do not work as effectively on underweight people and that a minimum body weight must be achieved for full effect to occur.

Treatment of eating disorders is difficult. However, it is most effective when using a multidisciplinary treatment team including a psychopharmacologist, a therapist, a nutritionist, and a primary care physician. There are currently limited psychopharmacologic interventions for the treatment of eating disorders. Fluoxitine has been shown by to decrease the urges to binge and to purge, as have desipramine and imipramine (Becker 1998). Topamax has been shown to decrease the urge as well, but it has the worrisome side effect of weight loss (Hedges 2003). Anorexia has been more difficult to treat both pharmacologically and therapeutically. Antipsychotics have begun to show promise with abnormal or inaccurate body image issues, but nothing has been shown to treat the underweight state of anorexia. Cognitive behavior therapy has proven to be effective in improving the outcome of patients with BN but not with AN.

Eating disorders carry with them a stigmatization that makes patients ashamed of and secretive about their behavior. One tactic to engage them in treatment is to isolate their illness as a force outside of their person. "Angel" called her eating disorder “the it” and gradually began to conceptualize it as an entity unto itself. She was able to accept the support of her treatment team with the understanding that “the it” was stronger than any one member of the team—but that together, she and her treaters were stronger. Angel was in treatment for seventeen years before she could eat out with her family. She is well versed in the high relapse rate of patients with eating disorders, but her committed relationship with her treatment team has kept her alive through three ICU stays and two suicide attempts.

Often the triumphs of working with eating-disordered patients are found in the small steps they achieve, such as eating more than one thousand calories for seven days straight. At other times the rewards are more remarkable: After eleven years of amenorrhea, Alyssa recently gave birth to her first child.

Adair Look, MD, is an Attending Psychiatrist in the Women's Health department of California  Pacific  Medical Center