Clinical Review

Anorexia Nervosa and Bulimia

Mark Scott Smith, MD Seattle, Washington

Anorexia nervosa may occur in one of 200 white adolescent girls, and bulimia appears to be much more common, particu­ larly in older adolescents and young women. These disorders are distinctly uncommon in the male population. Current opin­ ion supports a psychological basis for these disorders, al­ though there are some findings that suggest a primary hypotha­ lamic defect. Early warning signs of anorexia nervosa include an arrest in weight gain during puberty, increasing social isola­ tion, hyperathleticism, and increasing concern over academic performance. Bulimia may exist concomitantly with anorexia nervosa or as an entirely separate disorder characterized by a recurrent binge-purge cycle. The signs and symptoms of these eating disorders are mainly those associated with weight loss, dehydration, and electrolyte imbalance. Because of the com­ plex psychological issues involved, an experienced psycho­ therapist should be involved while the primary care clinician provides anticipatory and supportive medical care.

Anorexia nervosa is currently viewed as having sues such as mastery and control, sexuality, inap­ multiple interacting causes that include biological propriate expectations, and abandonment.1 vulnerability, early experiences, and family influ­ Bulimia may exist concomitantly with anorexia ences creating a psychological predisposition, social nervosa, as a subsequent clinical syndrome follow­ climate and cultural obsession, possible endocrine ing anorexia, or as an apparent distinct entity with changes, and psychological conflicts involving is- different psychological roots. The main clinical distinction between anorexia nervosa and bulimia involves starvation in the former and recurrent From the Children's Orthopedic Hospital and Medical Cen­ episodes of excessive food intake (binging) usually ter and the Division of Adolescent Medicine, Department of followed by vomiting or purging in the latter. Pa­ Pediatrics, School of Medicine, University of Washington, Seattle, Washington. Requests for reprints should be ad­ tients with anorexia nervosa usually become more dressed to Dr. Mark Scott Smith, Adolescent Services, Chil­ dren's Orthopedic Hospital and Medical Center, P.O. Box cachectic than those with bulimia.2 Patients with C5371, Seattle, WA 98105. anorexia and bulimia both share an extreme and

1984 Appleton-Century-Crofts

THE JOURNAL OF FAMILY PRACTICE, VOL. 18, NO. 5: 757-766, 1984 757 ANOREXIA NERVOSA AND BULIMIA unrealistic concern regarding body image, food, ly, she experiences a sense of failure and ineffec­ and eating behavior. tiveness, which may lead her to develop a symp­ In general, patients with anorexia nervosa are tom demonstrating superior personal control and resistant to therapy and usually are brought to the expressing accumulated anger against her parents. health care provider by another concerned indi­ The interpersonal relationships in these families vidual. Conversely, patients with bulimia unasso­ tend to be intense, with evidence of excessive ciated with anorexia nervosa frequently are very closeness among family members and a tendency concerned about their binge eating and vomiting toward overprotectiveness of one another. Bring­ and purging behavior and may present themselves ing these family issues to the surface and facilitat­ to health care providers for assistance in gaining ing alternative solutions requires the skills of an control over this compulsive activity. Bulimic pa­ experienced psychotherapist. tients are not easier to treat, however, since the Although current opinion supports a psycholog­ pattern of binge eating and vomiting or purging ical basis for anorexia nervosa and bulimia, with usually proves extremely difficult to disrupt. endocrine and other physical changes produced Because of the complex psychological aspects mainly as a consequence of severe weight loss, of these eating disorders, the involvement of an there are some intriguing aspects that lend support experienced mental health professional is strongly to the hypothesis of a primary organic etiology. indicated. Nevertheless, the primary care clinician Several studies have suggested a primary hypotha­ can play an important role in providing continuity lamic defect in anorexia nervosa.3,4 When exposed of care through anticipatory and supportive medi­ to increased environmental temperature, patients cal management. This paper is intended to provide with anorexia nervosa do not exhibit the initial the clinician with information and guidelines use­ core temperature decrease seen in normal subjects ful in the medical management of anorexia nervosa or in those with simple starvation, and they de­ and bulimia. velop a faster subsequent rise in temperature. Ex­ posed to a cold environment, they do not show the usual initial core increase and develop a faster subsequent decrease in core temperature. An­ orectic patients also do not exhibit shivering when exposed to a cold environment. In response to water deprivation, patients with anorexia nervosa Etiology do show an initial increased urine osmolality Family dynamics appear to be paramount in the greater than that of plasma, but an additional rise development of anorexia nervosa, although these is seen following the administration of vasopres­ factors have not been extensively evaluated in sin, suggesting the possibility of a partial diabetes bulimia. Although many exceptions occur, and it insipidus. is important to remain skeptical about the “typi­ Patients with anorexia nervosa frequently ap­ cal” family dynamics involved in anorexia ner­ pear to have a misperception of bodily sensations, vosa, several characteristics are quite common. At particularly of enteroceptive stimuli. Distortions first glance the family may appear to be a model of of satiety, sucrose aversion, and altered percep­ success, with parents presenting a satisfactory and tion of body image have been reported.5,6 In addi­ harmonious marriage. However, a general lack of tion, these patients often appear to fail to recog­ fulfillment as a couple appears to lead the parents nize their own affective states (eg, anger, anxiety, to overinvolvement and excessive expectation dis­ guilt) and frequently will deny fatigue. Unlike placed upon the children. Typically, a daughter, starvation victims, who are not active, anorexia who may be somehow vulnerable, becomes the nervosa patients often are driven to hyperathleti­ primary figure in this subconscious family issue. cism such as long-distance running and excessive She often feels she must be a model child in order calisthenic exercising. Since many patients with to please her parents, earn their acceptance, meet anorexia nervosa experience feelings of hunger their expectations, and make up for their personal that they pride themselves in resisting, the term disappointments and dissatisfactions with each anorexia is probably a misnomer. The German other. Since she is never able to do this complete - term Pubertaetsmagersucht, or “ leanness passion

758 THE JOURNAL OF FAMILY PRACTICE, VOL. 18, NO. 5, 1984 ANOREXIA NERVOSA AND BULIMIA

Table 1. DSM-III Diagnostic Criteria Table 2. DSM-III Diagnostic Criteria for for Bulimia11 Anorexia Nervosa11

Recurrent episodes of binge eating (rapid con­ Intense fear of becoming obese, which does sumption of a large amount of food in a dis­ not diminish as weight loss progresses crete period of time, usually less than two Disturbance of body image, eg, claiming to hours) "feel fat" even when emaciated At least three of the following: Weight loss of at least 25 percent of original Consumption of high-caloric, easily in­ body weight or, if under 18 years of age, gested food during a binge weight loss from original body weight plus Inconspicuous eating during a binge projected weight gain expected from Termination of such eating episodes by ab­ growth charts may be combined to make dominal pain, sleep, social interruption, the 25 percent or self-induced vomiting Refusal to maintain body weight over a mini­ Repeated attempts to lose weight by se­ mal normal weight for age and height verely restrictive diets, self-induced No known physical illness that would account vomiting, or use of cathartics or diuretics for the weight loss Frequent weight fluctuations greater than ten pounds due to alternating binges and fasts Awareness that the eating pattern is abnormal and fear of not being able to stop eating voluntarily Depressed mood and thoughts of self-depre­ and women, with a female:male ratio estimated to cation following eating binges be greater than 10:1.7 Male patients with anorexia Bulimic episodes not due to anorexia nervosa nervosa seem to have psychological characteris­ or any known physical disorder tics similar to those of women with the disorder.9 The incidence of anorexia nervosa peaks in early adolescence, whereas bulimia is more commonly a late adolescent phenomenon.7,10

of puberty,” may be more appropriate for this disorder. Diagnosis The Diagnostic and Statistical Manual o f Men­ tal Disorders, Third Edition11 (DSM-III) criteria for bulimia listed in Table I are useful to the pri­ mary care clinician. The diagnostic criteria for Incidence anorexia nervosa listed in Table 2 are likewise Since the eating disorders (particularly bulimia) helpful, although insisting upon a weight loss are most certainly underreported, it is difficult to equaling 25 percent of premorbid body weight may estimate their incidence. Although described for result in underdiagnosis of milder or incipient centuries, the prevalence of anorexia nervosa, and cases that might benefit from early intervention. most likely bulimia, is apparently increasing. The Typical development in the evolution of anorexia incidence of anorexia nervosa in white adolescent nervosa is depicted in Figure 1. Early warning girls in developed countries has been estimated to signs that should alert the clinician to this diagno­ be approximately 1 in 200.7 It appears that bulimia sis include arrest in weight gain during puberty, is much more common than anorexia nervosa, par­ increasing social isolation, increased athleticism, ticularly during late adolescence and young adult and an increased concern for perfect performance years.8 Anorexia nervosa is seen mainly in girls in academic endeavors. Early intervention that

THE JOURNAL OF FAMILY PRACTICE, VOL. 18, NO. 5, 1984 759 ANOREXIA NERVOSA AND BULIMIA

mobilizes the assistance of a mental health pro­ such as hyperthyroidism, adrenal insufficiency, fessional, coupled with ongoing supportive guid­ hypopituitarism, inflammatory gastrointestinal ance by the primary care clinician, may possibly disease, and brain tumor in the differential diag­ avert the development of a full-blown anorexia nosis of anorexia nervosa; but a meticulous his­ nervosa syndrome. tory and physical examination will usually suffice to rule out the likelihood of such disorders. In hyperthyroidism weight loss occurs despite normal or increased food intake. Although hyper­ activity is common, it does not take the form of vigorous exercise, and lethargy is a frequent Differential Diagnosis complaint. Tachycardia, rather than bradycardia, It is unlikely that in an amenorrheic adolescent, is present and thyroid hormone levels are ele­ the onset of weight loss with dieting, the desire for vated. Adrenal insufficiency may be associated extreme thinness, and the fear of weight gain will with poor appetite and hypotension, but lethargy be due to a disorder other than anorexia nervosa.12 and weakness are usually prominent symptoms. Although a rare case of a patient with an underly­ Increased skin pigmentation and a reduction of ing organic disorder may simulate anorexia ner­ pubic and axillary hair may be found on physical vosa, most of these patients present with some examination. In contrast to anorexia nervosa, clinical aspects that are inconsistent with the diag­ plasma cortisol levels are low but maintain normal nosis of primary eating disorder.13,14 Certainly the diurnal variation, and the adrenal response to clinician must consider occult organic conditions stimulatory tests is subnormal or absent. Pituitary

760 THE JOURNAL OF FAMILY PRACTICE, VOL. 18, NO. 5, 1984 ANOREXIA NERVOSA AND BULIMIA dysfunction also causes amenorrhea and must be dration, and electrolyte imbalance. Amenorrhea considered in the differential diagnosis of anorexia may precede significant weight loss in up to 25 nervosa. Craniopharyngioma is the most likely percent of patients with anorexia nervosa.17 Al­ cause of pituitary dysfunction in this age group, though some authors have suggested that this find­ although prolactin-secreting pituitary tumors must ing lends support to the hypothesis of an organic also be considered. Weight loss is not usually a etiology of anorexia nervosa, it is clear that most prominent feature of either tumor. of these patients are experiencing significant emo­ Gastrointestinal disease with malabsorption tional stress long before the onset of significant may result in weight loss, but should rarely be weight loss. Emotional distress is well established confused with anorexia nervosa. In inflammatory as a common cause of secondary amenorrhea in bowel disease there is usually a history of abdomi­ adolescent and adult women.18 Patients may nal discomfort and diarrhea, often with blood and complain of abdominal pain and constipation. De­ mucus. In celiac or other malabsorption syn­ creased gastric motility has been documented in dromes, steatorrhea is a prominent feature. When anorexia nervosa and may be associated with ab­ diarrhea is present in anorexia nervosa, it is usual­ dominal pain.19 Acute gastric dilatation and pan­ ly self-induced by laxatives and is frequently not creatitis may occur during periods of refeeding.20 volunteered as a symptom. Constipation may be related to relative dehydra­ Poor appetite with weight loss may be a feature tion or simply scant stools due to sparse food in­ of severe depression or schizophrenia. The pres­ take mislabeled as constipation by the patient. In ence of diagnostic features of these disorders and addition, many patients with eating disorders the absence of abnormal desire to lose weight abuse laxatives and may become confused regard­ usually allow differentiation from anorexia ner­ ing normal bowel habits.21 Other symptoms that vosa. Although symptoms of depression frequent­ may be volunteered include cold intolerance, dry ly accompany anorexia nervosa, the characteristic skin, and brittle hair and nails, which are probably features of the underlying syndrome are usually due to loss of subcutaneous fat and malnutrition, predominant.15,16 but decreased tri-iodothyronine levels (reflecting Severe physical illness, such as tuberculosis a compensatory decreased metabolic rate, not and malignancy, will usually be accompanied by hypothyroidism) may also contribute to these obvious physical symptoms or signs other than symptoms.22 weight loss and amenorrhea. Lethargy and malaise, rather than hyperactivity, are usually prominent, and there is not an abnormal desire for thinness. In the differential diagnosis of bulimia, one must consider esophageal and gastrointestinal dis­ orders, metabolic abnormalities, and tumors of the central nervous system. Although changes in per­ Physical Findings sonality and vomiting behavior may occur with The physical findings in anorexia nervosa are tumors of the central nervous system, and a care­ essentially the same as those found in any starva­ ful neurological examination with visual field as­ tion state. Subcutaneous fat is lost and the skin sessment is mandatory, the binge-purge or -vomit may be dry and inelastic with a yellowish caroten- cycle and an excessive concern about body image are emic hue. The occasional petechiae that may be not typical of these disorders. noted are presumably due to increased capillary fragility and are not related to a coagulation disor­ der. Body temperature is low and bradycardia with decreased blood pressure may be noted. Pos­ tural hypotension is a frequent finding. Pubic and axillary hair is preserved and lanugo may appear, predominantly on the extremities. Peripheral Signs and Symptoms edema may be noted, particularly during times of The signs and symptoms of these eating disor­ refeeding. Parotid swelling of unclear etiology23 ders are those associated with weight loss, dehy­ and increased dental caries possibly related to re-

THE JOURNAL OF FAMILY PRACTICE, VOL. 18, NO. 5, 1984 761 ANOREXIA NERVOSA AND BULIMIA current contact with acidic vomitus or excessive rhythm.35,36 Dexamethasone suppression tests carbohydrate intake during binging2 may be noted may yield inadequate responses.37 Gonadotropins in bulimic patients. Anthropometric measure­ are decreased, frequently to prepubertal ranges.38 ments using a tape measure and calipers will pro­ Although thyroxine and thyroid-stimulating hor­ vide indices for estimation of chronic undernour­ mone are in the normal range, tri-iodothyronine ished states. Patients with longstanding starvation levels are frequently decreased.39 This decrease may show significant decrease in both fat and probably represents a basal metabolic rate normal­ muscle measurements. ized for body mass with decreased peripheral con­ version of thyroxine to tri-iodothyronine and is not an indication for treatment with thyroid medication.

Laboratory Evaluation With the exception of values indicating fluid and electrolyte imbalance, the laboratory evalua­ Management tion of these eating disorders is of minimal assist­ The initial medical evaluation of the adolescent ance in clinical management. Repetitive vomiting with an eating disorder should include a thorough or use of laxatives may produce metabolic abnor­ history and physical examination coupled with the malities, the most common of which is hypokalemic, selective use of a few indicated laboratory studies. hypochloremic alkalosis.24 Occasionally diuretic A “ shotgun” approach with multiple laboratory abuse is also encountered, which may compound and radiologic procedures is costly and has a low this metabolic state.25 Electrocardiography may diagnostic yield. The amenorrheic patient with reflect these metabolic abnormalities as well as the diet-induced weight loss, an expressed desire for hypometabolic state (bradycardia, low voltage).26 extreme thinness, and inordinate fear of weight Cerebral atrophy, probably secondary to malnu­ gain who has no signs or symptoms of other or­ trition, has been noted by computed tomography ganic disease requires little laboratory investiga­ in patients with anorexia nervosa.27 tion. A recommended initial medical evaluation of Glucose levels are generally maintained in a low the adolescent with an eating disorder includes a normal range.28,29 Anemia is not usual except in urinalysis, complete blood count, erythrocyte severely emaciated patients.30 Leukopenia is fre­ sedimentation rate, and serum electrolytes. Clear­ quently present but does not appear to be associ­ ly, the more atypical features there are in a patient ated with an increased risk of infection.31 Serum with suspected anorexia nervosa, the more consid­ albumin levels are maintained in the normal range eration must be given to alternative diagnoses. Lab­ in all but the most severely malnourished cases.30 oratory studies should be selected accordingly. Although low in other forms of weight loss, serum Because anorexia nervosa and bulimia are carotene levels are frequently elevated in anorexia complex and chronic disorders, a multidisciplinary nervosa.32 The mechanism, which does not appear approach to therapy is recommended. Although to be related solely to increased intake, is un­ the efficacy of psychotherapy in these eating dis­ clear.33 Serum carotene levels have been reported orders has not been clearly established in well- to be elevated in patients with anorexia nervosa, controlled studies, the early involvement of an but not in those with bulimia.34 While these find­ experienced mental health professional is strongly ings relating to serum carotene are interesting, recommended. The natural course of anorexia they are rarely useful in the clinical management nervosa, at least that portion of the syndrome re­ of these eating disorders. flected by severe weight loss, commonly extends The endocrine aspects of anorexia nervosa are over a three- to four-year period.40,41 Although intriguing but, with the exception of amenorrhea, psychological problems, excessive concern over do not appear to be clinically significant. Growth food and body image, and, not infrequently, obe­ hormone and cortisol are frequently increased, sity may follow this initial active period of and the latter may or may not lose its diurnal anorexia nervosa,42 the life-threatening aspect of

762 THE JOURNAL OF FAMILY PRACTICE, VOL. 18, NO. 5, 1984 ANOREXIA NERVOSA AND BULIMIA the disorder will usually subside with time. The experience of gaining weight. The clinician, al­ natural course of bulimia is unclear, but it appears though often exasperated by this behavior, should that it may persist unabated for many years, pos­ avoid taking it as a personal affront and respond­ sibly becoming a lifetime problem.43’44 With this ing punitively. perspective regarding the chronicity of these dis­ The primary care clinician should attempt to orders in mind, it is obvious that continuity of develop a therapeutic relationship with the adoles­ therapy is desirable. In addition to mental health cent with an eating disorder based upon the same assistance, an experienced nutritionist who is principles of concern, mutual respect, and trust comfortable working with adolescents with eating that are applied to any adolescent patient. Obvi­ disorders can be helpful. Although these patients ously, the establishment of trust in a conventional are clearly not suffering from a primary nutritional sense frequently is impossible. However, the cli­ disorder, the practical advice and guidance of a nician can impart to the patient a sense of trust nutritional authority can be helpful in reducing that ultimately all therapeutic efforts are for the anxiety and guiding the patient toward more sound patient’s benefit and do not represent arbitrary ef­ nutritional practices. forts to impose external control. The clinician Clearly, all health professionals involved in the should not assume that the adolescent with an eat­ care of patients with eating disorders must be pre­ ing disorder will be noncompliant in all areas. Al­ pared to deal with their own feelings of frustration, though resistant to food intake and weight gain, impatience, and, occasionally, anger. In the inter­ these patients frequently will comply with regi­ disciplinary approach, it is important to establish mens such as potassium therapy when the treat­ the roles of each provider, since adolescent pa­ ment rationale is clearly presented. tients with eating disorders are frequently adept in The patient who is severely compromised in nu­ the art of playing one member of the team against tritional status should be seen weekly. Weight, another. Regular communication among members blood pressure, and electrolyte determinations (if of the team is important in this regard. Optimally, the patient is vomiting or purging) are indicated the role of the primary care clinician should focus measures. The clinician should regularly ask about upon the physical aspects of the disorder, while eating behavior, vomiting, and laxative and diure­ management of psychological issues such as fam­ tic use. These questions should be presented in a ily conflict and feelings of helplessness are de­ concerned and noncritical manner. The clinician ferred to the mental health professional. However, should also inquire regarding other specific con­ general supportive counseling and assistance in cerns of the patient. Whether the clinician should stress management may be appropriate roles for relate to the patient a specific weight at which the primary care clinician. hospitalization would be mandatory is debatable. The role of the primary care clinician is often The clinician should have in mind criteria for hos­ difficult, since the adolescent with an eating disor­ pitalization such as continued weight loss below der is typically unable to address rationally the a certain limit or accelerated weight loss or in­ issues of nutrition, food intake, and body image. creased vomiting behavior. Life-threatening con­ The clinician must realize that it is not possible to ditions that mandate immediate hospitalization assume personal responsibility for the nutritional include shock, arrhythmia, and infection. Signifi­ status of the patient. Presenting ideal body weight cant dehydration with an orthostatic drop in blood charts, lecturing on nutrition, or performing pressure of greater than 15 mmHg, severe hypoka­ caloric counts at clinic visits is not helpful and lemia, and greater than 40 percent loss from nor­ simply will not be heard by the patient. Acknowl­ mal body weight or 25 to 30 percent loss occurring edging the difficulty the patient is having with within three months are also indications for hospi­ weight management and expressing clinical con­ tal admission with fluid, electrolyte, and nutri­ cern over nutritional and metabolic status are tional therapy.45 strongly indicated. There is no clear evidence that any psycho­ Although frequently suggesting cooperation and tropic medication changes the course of anorexia a desire to comply with medical therapy, the pa­ nervosa or bulimia. Antidepressant medication tient with an eating disorder often employs deceit may ameliorate significant dysphoric states, but and subterfuge in the effort to avoid the frightening usually will not affect the underlying eating disor-

THE JOURNAL OF FAMILY PRACTICE, VOL. 18, NO. 5, 1984 763 ANOREXIA NERVOSA AND BULIMIA der. A few reports have suggested that certain Hypokalemia, usually induced by repeated drugs (eg, carbamazepine, monoamine oxidase in­ vomiting, is frequently associated with eating dis­ hibitors) might be useful in some individuals with orders. The primary clinician should regularly eating disorders, but no well-designed large pro­ question the patient regarding vomiting, laxative spective study has supported their efficacy.46'47 abuse, or the use of diuretics. In contrast to Appetite stimulants such as cyproheptadine have sodium, the kidney is unable to eliminate potas­ not been shown to be useful in anorexia nervosa.48 sium completely. Even with a serious deficit, 5 to Metoclopramide may alleviate symptoms with de­ 15 mEq of potassium are excreted per day.52 creased gastric motility in anorexia nervosa.49 Al­ Potassium excretion is enhanced by the following though vitamin deficiency has not been docu­ factors: (1) increased sodium delivered to the dis­ mented in anorexia nervosa, pragmatic vitamin tal tubule (diuretics), (2) alkalosis increasing intra­ supplementation may be appropriate. In patients cellular potassium, which is then available who are vomiting or purging frequently, potassium for exchange at the lumenal border (vomiting), supplementation is frequently necessary. (3) increased mineralocorticoid with increased ex­ change of potassium for sodium at the distal tubule (hypovolemia), (4) nonreabsorbable anion at the distal tubule (chloride is better reabsorbed than bicarbonate; in chloride deficiency associated with vomiting or diuretics, only cation is ex­ changed with potassium for sodium), and (5) in­ Common Management Problems creased urine flow (partial diabetes insipidus?). Decreased fluid intake, vomiting, and laxative Early symptoms of hypokalemia (muscle weak­ and diuretic abuse may lead to significant prob­ ness, lethargy) may be ascribed to the starvation lems with volume depletion and electrolyte imbal­ state. Progressive hypokalemia leads to nausea ance. Orthostatic hypotension is diagnosed when a and vomiting, ileus and abdominal distention, standing blood pressure taken two minutes after muscular paralysis, and potentially fatal cardiac a supine measurement shows a profound drop in arrhythmias. Patients with persistent vomiting systolic blood pressure of 15 to 30 mmHg, and a may need regular potassium supplementation. diastolic drop of greater than or equal to 30 beats/ Congestive heart failure has been reported in phys­ min. In addition to volume depletion, fasting may ically active anorexia nervosa patients during vol­ be associated with decreased sympathetic nervous ume depletion.53 Weakened cardiac muscle, pa­ system tone and increased endogenous opiate ac­ tient overactivity, and volume overload appear to tivation, which further decrease blood pressure.50 be significant factors.54'55 Fortunately, these Frequent vomiting may be associated with chronic patients usually respond to the simple measures sore throat, parotid swelling, dental caries, and of volume restriction and diuretic agents. gastric dilatation.2 43 Mean levels of follicle-stimulating hormone Laxative or diuretic abuse may lead to hypo­ (FSH) and luteinizing hormone (LH) are signifi­ chloremic alkalosis with seriously depleted potas­ cantly lower in anorectic and many bulimic pa­ sium stores.21'25 Although phosphate may be tients than in healthy women or girls of compara­ reduced with inadequate intake and markedly so ble developmental stage.38 Twenty-five percent of during refeeding following starvation states, ca­ anorectic patients become amenorrheic prior to tabolism results in the release of intracellular significant weight loss.17 At less than 75 percent of stores of phosphate. Moderate levels of hypo­ the initial body weight, the pubertal progression of phosphatemia seen in untreated eating disorders gonadotropin release is reversed, and a correlation appear to be well tolerated. Severe hypophospha­ exists between the degree of weight loss and the temia (less than 1.0 mg/dL), which may result in lack of maturity of circadian LH secretion. With serious consequences (eg, rhabdomyolysis, he­ restoration of the initial body weight and remission molysis, myocardial dysfunction), is rarely seen of psychological symptoms, the adult gonado­ except in the most severe cases of malnutrition tropin pattern is resumed. It has been reported, or during refeeding without adequate phosphorus however, that patients who regain their initial intake.51 body weight but retain the psychological symp-

764 THE JOURNAL OF FAMILY PRACTICE, VOL. 18, NO. 5, 1984 ANOREXIA NERVOSA AND BULIMIA toms of anorexia may experience persistent imma­ When the anorectic patient is hospitalized, the ture patterns of gonadotropin secretion.56 The clinician should monitor ward staff relationships mechanism of hypothalamic dysfunction and with the patient. Anticipation of efforts at decep­ amenorrhea with weight loss is unclear. Estrogen tion is indicated, and nonpunitive behavioral balance may be related to the percentage of body modification techniques are often helpful. Clear weight composed of fat. Catecholestrogens are in­ role definition among the health professionals (eg, creased in anorexia nervosa and may produce an nutritionist, nurse, psychotherapist, primary care antiestrogen effect as well as inhibit gonadotropin clinician) is important, and regular communication release.38 through team meetings is necessary. Amenorrheic individuals, such as significantly The most difficult issue for the clinician, im­ malnourished patients with anorexia nervosa, will plicit in all aspects of care of the patient with usually have low levels of gonadotropins. Patients anorexia nervosa, is the right of the individual to with borderline nutritional states such as those act in a self-destructive manner and ultimately to with bulimia, however, may have enough gonado­ die. Since the psychodynamics of this disorder tropin secretion to produce an endometrial suggest that control over his or her own body is effect without sufficient levels of progesterone the final perceived power the adolescent with (analogous to secondary amenorrhea in otherwise anorexia nervosa maintains, therapeutic efforts healthy women). This unopposed estrogen effect toward correcting self-induced starvation are may cause continued stimulation of the endome­ necessarily in opposition to this conviction. For­ trium with possible long-term deleterious effect. In tunately, most patients respond to therapy well these individuals, periodic induction of menses enough to prevent death, even though typically with progesterone may be indicated. The ultimate maintaining precariously low body weights for prognosis for menstruation and subsequent fertility several years. Some patients, however, will resist following weight gain appears to be good, even after all efforts toward nutritional support, subtly sabo­ years of amenorrhea. Once pregnant, gestational taging intravenous lines and nasogastric feeding weight gain is usually normal, and pregnancy, tubes while gaining no insight from psychother­ labor, and delivery appear to be uncomplicated.38 apy. Although legal commitment and forced feed­ ing may be instituted, there is no clear answer to this dilemma, and the truly resistant, determined patient with anorexia nervosa may ultimately die.

Hospitalization Given the long clinical course of anorexia ner­ vosa and bulimia, hospitalization does not repre­ sent a cure. Short-term hospitalization may be necessary for severe nutritional and metabolic de­ rangement. Longer term hospitalization may stabi­ lize these patients through behavior modification, milieu therapy, or family and individual psycho­ therapy. Recent reviews have described several types of programs.57'59 In determining criteria for References discharge from prolonged hospitalization, both 1. Lucas AR: Toward the understanding of anorexia weight gain and psychological status should be nervosa as a disease entity. Mayo Clin Proc 56:254, 1981 2. Pyle RP, Mitchell JE, Eckert ED: Bulimia: A report of considered. Recommended discharge criteria in­ 34 cases. J Clin Psychiatry 42:60, 1981 clude a weight for height greater than or equal to 3. Mecklenburg RS, Loriaux DL, Thompson RH, et al: Hypothalamic dysfunction in patients with anorexia ner­ the 25th percentile and evidence that the patient is vosa. Medicine 53:147, 1974 motivated to maintain a minimal nutritionally ac­ 4. Gold MS, Pottash ALC, Sweeney DR, et al: Further evidence of hypothalamic-pituitary dysfunction in anorexia ceptable weight and continue in a psychothera­ nervosa. Am J Psychiatry 137:101, 1980 peutic relationship as an outpatient. 5. Crisp AH, Kalucy RS: Aspects of the perceptual dis-

THE JOURNAL OF FAMILY PRACTICE, VOL. 18, NO. 5, 1984 765 ANOREXIA NERVOSA AND BULIMIA

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