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Current P SYCHIATRY CP_12.05_Cloak.finalREV 11/16/05 12:33 PM Page 65 Current p SYCHIATRY Are undiagnosed eating disorders keeping your patients sick? Undetected binge eating, anorexia, or bulimia can thwart other psychiatric therapies Nancy L. Cloak, MD Staff psychiatrist, MDSI Physicians, Inc. Portland, OR Pauline S. Powers, MD Professor, department of psychiatry University of South Florida, Tampa he internist next door asks you about his T patient with bulimia, who routinely has po- tassium levels of 2.0 mEq/L. “She admits it’s a prob- lem but thinks she’ll get fat if she stops purging. What can I tell her to get her into treatment?” That afternoon, your longtime patient Mr. J—age 56 with depression, obesity, and hypertension— arrives for his appointment. With the day’s earlier con- versation in mind, you ask him if he has an eating problem. Staring at the floor, he describes a lifelong battle with nighttime eating binges, which he has never mentioned to you before. Mr. J may have concealed his binge eating because of shame or ambivalence about stopping a psycho- logically protective behavior. And his eating disor- der may be complicating his depression treatment. © Dianna Sarto/CORBIS continued VOL. 4, NO. 12 / DECEMBER 2005 65 CP_12.05_Cloak.final 11/15/05 3:20 PM Page 66 Eating disorders • Among 62 patients with a primary diag- Box nosis of obsessive-compulsive disorder, ‘Subsyndromal’ eating disorders: 13% had anorexia or bulimia nervosa and Most common in outpatient practice another 18% met subthreshold criteria.6 • In 257 female patients with anxiety disor- Some 40% of persons with eating disorders meet ders, nearly 12% also met criteria for a pos- DSM-IV-TR criteria for anorexia or bulimia nervosa. sible eating disorder.7 The other 60%—with eating disorder, not otherwise Overlapping symptoms. Co-morbid eating disor- specified (ED-NOS)—are divided nearly evenly between ders can be difficult to detect because their psy- binge eating disorder and subsyndromal anorexia or bulimia. Outpatient psychiatrists see these eating chological symptoms resemble those of Axis I disorders most often. and Axis II disorders. Physiologist Ancel Keys Anorexia and bulimia nervosa prevalence rates reported depression, apathy, low motivation, are estimated to be 0.3% and 1%, respectively.3 But tiredness, weakness, anhedonia, and decreased including ED-NOS patients increases the overall cognitive efficiency in 32 healthy male volun- eating disorder prevalence to 2% to 3%—equal to teers who follow a semi-starvation diet (1,600 or greater than the combined rates of schizophrenia kcal/d) for 24 weeks.8 and bipolar I disorder. Although considered “subsyndromal,” ED-NOS patients suffer psychopathology, impairment, and WHO HAS EATING DISORDERS? medical comorbidity similar to those of persons Most eating disorder patients are adolescent who meet DSM-IV-TR criteria for anorexia or bulimia girls or young women with pronounced body nervosa.4 image dissatisfaction. Other patients include: Atypical young women. Some young women— But outpatient psychiatrists can often manage usually Asian—meet most criteria for anorexia ner- patients like Mr. J in consultation with a nutrition- vosa but lack the characteristic drive for thinness. ist and primary care physician. Eating disorders are They tend to have less psychopathology and better treatable,1,2 and many patients can recover. This prognosis than typical female patients.9 article describes how to identify eating disorders so Boys and men. Female-to-male ratios are approxi- that treatment can begin. mately 11:1 for anorexia, 5:1 for bulimia, and 3:1 for binge eating disorder. Men and boys with eating PSYCHIATRIC COMORBIDITY disorders are similar to their female counterparts Eating disorders are common in outpatient prac- but are more likely to report: tice (Box)3,4 and coexist with a variety of psychiatric • comorbid substance abuse diagnoses (Table 1). For example, in 248 women • having begun weight loss and purging in with anorexia, bulimia, or unspecified eating disor- response to teasing or concerns about health, ders, 74% had another Axis I disorder, including: sports performance, or gay relationships, • anxiety disorders (54%) rather than appearance.10 • affective disorders (52%) Children may present with somatic complaints, • substance-related disorders (25%). obsessive-compulsive disorder, and depression. The most-common Axis II disorders belonged Rapid weight loss with dehydration and medical to cluster C (53%) or cluster B (21%).5 compromise is more common than in older eat- Eating disorders also are much more common ing disorder patients, and growth retardation— in persons who present with psychiatric problems sometimes irreversible—can occur.11 than in the general population. For example: Middle-aged to late-life. Midlife onset of eating dis- 66 Current VOL. 4, NO. 12 / DECEMBER 2005 p SYCHIATRY CP_12.05_Cloak.final 11/15/05 3:20 PM Page 67 Current p SYCHIATRY orders may be precipitated by losses or Table 1 concerns about aging. In the elderly, Common psychiatric comorbidities eating disorders may be manifestations in patients with eating disorders of complicated bereavement, and ruling out medical causes of weight loss is cru- Disorder Comorbidities cial in this age group. Anorexia and Anxiety disorders (social phobia, Night-eating syndrome. Some patients bulimia nervosa PTSD, OCD) eat at least 25% of daily calories after the Mood disorders (major depressive disorder, dysthymia, bipolar disorder) evening meal. They experience insom- Substance use disorders (more nia, morning anorexia, and sometimes common in patients who binge amnesia for the nocturnal eating and/or purge) episodes. Anxiety, depression, or sleep Personality disorders (cluster C more disorders may be contributing factors.12 common in restricting anorexia, cluster B more common in patients IDENTIFYING EATING DISORDERS who binge and purge) Screening. No formal guidelines rec- Binge eating Anxiety disorders (PTSD) ommend which psychiatric patients to disorder Mood disorders (major depressive screen for eating disorders. We suggest disorder, bipolar disorder) screening any patients who are over- or PTSD: posttraumatic stress disorder underweight or have eating disorder OCD: obsessive-compulsive disorder risk factors, such as: • young women (teens and early 20s) • weight history (premorbid, lowest, highest, • athletes in certain sports (gymnastics, bal- and preferred weights). let, figure skating, running, body building, Bingeing and purging. If the patient acknowledges wrestling) bingeing, ask about its onset, frequency, triggers, • history of childhood sexual abuse.13 and consequences. Obesity is Suggested questions include, common in patients who binge, “How do you feel about your but a person can meet diagnostic cri- weight?” and “Do you ever binge Eating disorders’ teria for binge eating disorder without eat?” If responses suggest an eat- psychological being obese. ing disorder, interview thoroughly symptoms resemble DSM-IV-TR defines binging as con- while being sensitive to patients’ those of Axis I and suming a large quantity of food in a discrete shame and ambivalence. Axis II disorders time and feeling out of control of eating. Interviewing. Evaluate all 4 illness Ask specifically how the patient defines domains—nutritional, medical, “binge,” and seek details of a typical psychological, and social. Because patients often binge. Also ask about compensatory do not volunteer information, ask about: behaviors (purging by vomiting or • symptoms and complications using laxatives or diuretics). Is the patient abusing • onset and development of eating and ipecac, diet pills, or thyroid hormone? Does he or weight problems she fast or exercise compulsively (such as even • history of being teased or criticized while ill)? about weight Eating and exercise patterns. Ask the patient to VOL. 4, NO. 12 / DECEMBER 2005 67 CP_12.05_Cloak.final 11/15/05 3:20 PM Page 68 Eating disorders Table 2 Potential medical complications of anorexia and bulimia nervosa Organ system Symptoms Signs, syndromes, laboratory abnormalities Cardiovascular Palpitations, dyspnea, Bradycardia, orthostasis, acrocyanosis chest pain, dizziness Prolonged PR and QTc intervals on ECG, mitral valve prolapse, cardiomyopathy in ipecac abusers CNS Anxious, depressed, Enlarged ventricles on CT or MRI, deficits or irritable mood; on neuropsychological testing, abnormal obsessiveness; cognitive EEG, signs of peripheral neuropathy deficits; seizures (rare) 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, Abnormal bowel sounds, delayed gastric spontaneous vomiting, emptying, superior mesenteric artery reflux, abdominal pain, syndrome, pancreatitis heartburn, hematemesis 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 ↓ K, Na, Mg, phosphate; ↓cholesterol; CNS manifestations metabolic alkalosis (from vomiting), or acidosis (from laxatives); thiamin and niacin deficiencies (rare) Musculoskeletal Weakness, cramps, Wasting,
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