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Clinical Review Anorexia Nervosa and Bulimia

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Clinical Review Anorexia Nervosa and Bulimia 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
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