Remuda Ranch

Psychopharmacology in Patients with Eating Disorders

Kevin Wandler, MD
Division of Medical Services
Remuda Programs for Eating Disorders

Abstract. This article discusses psychopharmacological interventions with eating disorder patients as well as the role of the psychiatric provider in eating disorder treatment teams. Psychopharmacology with eating disorders is a complex topic. This article is an overview based on the existing research and the experience of Remuda’s psychiatric staff in treating 5000 eating disorder patients over the past 13 years. It is intentionally written to be readily understood by the non-medical healthcare provider.

Psychiatric Medication Philosophy

The last issue of The Remuda Review presented a Biblical understanding of eating disorders. This understanding suggests that we live in a broken world, including genetic abnormalities, toxic environmental conditions, and physical injuries that negatively alter human biochemistry. Many eating disorder patients experience such biochemical alterations. These alterations can lead to emotional and behavioral problems, including depression, anxiety, addictions, obsessive compulsive behaviors, and eating disorders. For many patients who are honestly struggling to free themselves from their eating disorder, recovery is more difficult because of these biochemical problems. The words of Jesus reflect such difficulties,"…the spirit is willing but the flesh is weak" (Matthew 26:41) New International Version.

At Remuda, we believe that the best way to restore biochemical health is through proper nutrition and time, combined with prayer and scientifically-valid/Biblically-based psychotherapy. The body was designed with certain nutritional requirements. When met, it can often restore itself biochemically. Research has also amply demonstrated that healthy spirituality and psychotherapy both directly affect human biochemistry in positive ways. As we described in the last issue of The Remuda Review, human beings are bio-psycho-social-spiritual creatures, and these several dimensions interact dynamically.

For many persons with eating disorders, the biochemical issues are substantial enough that additional pharmacological intervention is necessary. Because we are bio-psycho-social-spiritual entities, medication is never a cure-all. But with prudent consideration, a psychiatric provider is often able to find an appropriate medication and the right daily dosage for beneficial effects. Psychiatric medications do not produce artificial euphoria or pleasure, but lessen symptoms such as painful obsessive thoughts, anxiety, insomnia, and depression so that the individual can function more normally. Medication can give the patient a level playing field to deal with life's struggles.

Some Christian individuals and families have concerns about the use of psychotropic medicines. Although the Bible does not explicitly promulgate the use of such medicines, Jesus confirmed that the sick need a doctor (Matthew 9:12), and Luke, a Gospel writer, was a physician. Billy Graham, a prominent interpreter of Scripture, suggested the following to a mother who was advised that her son needed a prescription for psychotropic medication:

Much has been discovered in recent years about the human mind, and one finding is that our brains depend on literally hundreds of different chemicals in order to function properly. When one of these is missing or out of balance, it can have a serious effect on our behavior, and medications sometimes can help overcome this. While you should be cautious about putting your son (daughter or yourself) on any kind of medication, make your decision in light of your doctor's advice. The Bible does not discourage us from using medicine where necessary.

Remuda’s perspective is consistent with Graham’s wisdom. We recognize that "every good…gift is from above…" (James 1:17). Because medications may correct legitimate biochemical problems that cannot be addressed in other ways, medications are among God’s good gifts.

Remuda does not utilize alternative or homeopathic medicines. There is simply insufficient research on these compounds to know whether they are truly effective or not and how they interact with one another as well as with allopathic medications (O’Mathuna & Larimore, 2001). Because "Every prudent man acts out of knowledge..." (Proverbs 13:16), with insufficient information about these products it is premature to employ them in treating patients with eating disorders.

It should also be stressed that habit-forming or addictive medications are rarely needed or used. When prescribed, they are used according to current medical standards to minimize the chances of abuse or habituation. Patients are educated about potential side effects and are monitored closely by medical professionals.

Psychopharmacological Treatment of Eating Disorder Symptoms

Becker, Hamburg, & Herzog (1998) completed a comprehensive review of the literature on psychopharmacology with eating disorder patients. The review suggested only a few psychotropic medications indicated in the treatment of eating disorders, as follows:

To treat the symptoms of anorexia nervosa:

• Fluoxetine (Prozac®), for weight recovered anorexic patients only. Helps with relapse prevention. Obviously, because of the need to wait until weight restoration, this medication is not helpful in the management of acute anorexia.
• Cyproheptadine (Periactin®). This medication is similar to Benadryl® and is an antihistamine that causes weight gain. Its side effects include drowsiness and dizziness, especially in someone who is weight compromised, limiting its utility in patients with anorexia.

To treat the symptoms of bulimia nervosa:

• Imipramine (Tofranil®) and desipramine (Norpramine®). These medications are used less often now that a safer class of antidepressants, the selective serotonin reuptake inhibitors (SSRIs), have become available.
• Phenelzine (Nardil®) and isocarboxazid (Marplan®), antidepressants known as a monoamine oxidase inhibitors (MAOIs). MAOIs are not safe for someone with bulimia. Accidentally bingeing on a food class that interacts with these medications could make a patient extremely sick. Also, in treating eating disorders, so as not to promote additional focus on food, it is important to avoid medications that require a restricted diet.
• Bupropion (Wellbutrin®). Following the literature review, Bupropion became contraindicated for eating disorders due to the potentiation of seizure activity.
• Fenfluramine (Pondamine®). This has since been taken off the market.

This review demonstrates that there are no completely effective and safe medications to treat the most obvious behavioral symptoms of anorexia and bulimia. However, antidepressant agents are helpful with relapse prevention once the patient is in good recovery. Anti-anxiety agents and antipsychotics are also very helpful in the short term, quickly reducing the anxiety and distorted thinking commonly associated with eating disorders. In truth, the psychiatrist can be most effective in treating these related issues and the substantial comorbidity often found among eating disorder patients (Herzog, Keller, Sacks, Yeh, & Lavori, 1992).

The Prevalence of Psychiatric Comorbidity

Herzog et al. (1992) found that 73% of patients with restricting anorexia, 82% of those with binge-eating/purging anorexia, and 60% of those with bulimia had one or more concurrent comorbid Axis I diagnoses. Others (Zaider, Johnson, & Cockell, 2000) have reported lifetime Axis I comorbidities ranging from 80% and 97% across eating disorders. Psychiatric comorbidity complicates eating disorder treatment by contributing to eating disorder severity, chronicity, treatment resistance, medical complications, and poor outcome (Blinder, Chaitan, & Goldstein, 1986; Bulik, 2002).

Many studies have documented the frequent comorbidity of eating disorders with mood, anxiety spectrum, and substance use disorders (e.g., Blinder, Blinder, & Sanathara, 1998; Braun, Sunday, & Halmi, 1994; Grilo, Levy, Becker, Edell, & McGlashan, 1996; Herzog, et al., 1996; Iwasaki, Matsunaga, Kiriike, Tanaka, & Matsui, 2000; Striegel-Moore, Garvin, Dohm, & Rosenheck, 1999; Zaider, et al., 2000). Across investigations, as much as 98% of eating disorder patients have been diagnosed with comorbid mood disorders, 65% with comorbid anxiety disorders, and 55% with comorbid substance use disorders. Recent studies have also begun to emphasize the delusional quality of distorted body perception (e.g., Gordon, et al., 2001; Mavrogiorgou, Juckel, & Bauer, 2001; Mehler, Wewetzer, Schulze, Warnke, Theisen, & Dittmann, 2001; Powers, Santana, & Bannon, 2002).

Treating Comorbid Mood Disorders

In 2000, The American Psychiatric Association revised and updated the Practice Guidelines for the Treatment of Patients with Eating Disorders, stating that "psychotropic medications should not be used as the sole or primary treatment for anorexia nervosa. The role of antidepressants is usually best assessed following weight gain" (American Psychiatric Association, 2000). However, there are subtleties to consider.

Antidepressants are not very effective for patients with extremely low body fat. Most psychotropic medications are lipophilic, which means that after they are absorbed they enter the body’s fat tissue. The medication is then released back into the blood stream from the fat tissue. If body fat is low, little medication is absorbed and not much can be released. As a result, relatively high antidepressant dosages may be used with anorexic patients and given several times a day. This may increase blood levels and improve efficacy.

All antidepressants "recycle" amino acids. Amino acids come from food. Eating disorder patients may therefore lack sufficient amino acids to complete this cycle. Fortunately, in an eating disorder treatment facility where caloric intake is carefully monitored and amino acids are being ingested regularly, it may be useful to begin antidepressants while patients are in a weight recovery program.

For these reasons and because depression is a life threatening illness, we typically start depressed patients on an SSRI even during weight restoration. Many of these medications have been spotlighted in the media, such as fluoxetine (Prozac®), paroxetine (Paxil®), sertraline (Zoloft®), fluvoxamine (Luvox®) and citalopram (Celexa®). All five essentially do the same thing—recycle the naturally occurring neurotransmitter called serotonin— but there are many types of serotonin and serotonin receptors in the brain. As a result, these SSRIs are chemically different from each other and have different side effects. Clinicians may use some of these other characteristics to choose the specific antidepressant for a particular patient. Fluoxetine is stimulating and would be considered for someone with low energy. Paroxetine is sedating and may be chosen for someone with a sleep disturbance or high anxiety. None of the SSRIs significantly change weight, especially during a relatively short stay in inpatient treatment.

Venlafaxine (Effexor®) and venlafaxine XR (Effexor XR®) are also very effective in the treatment of depression. In addition to "recycling" serotonin, they also affect another neurochemical system, the noradrenergic system. The noradrenergic system "recycles" norepinephrine. This system provides energy and improves mood.

Bupropion (Wellbutrin®) and bupropion-SR work by "recycling" norepinephrine as well as dopamine, which is helpful for anxiety. Because of the risk of seizures in patients with bulimia, bupropion is used only after SSRIs have been tried and have failed. It can be considered for refractory depression if the patient is given a clear explanation of the risk of seizures. Bupropion SR may be the best delivery route for this medication. As a sustained release product, it is absorbed into the bloodstream more slowly, thus posing a lower seizure risk. Bupropion related seizures were not seen in patients with anorexia.

Many physicians are prescribing mirtazapine (Remeron®) for patients with anorexia. This antidepressant is sedating, and has been shown to cause weight gain. While the weight gain side effect may sound ideal for anorexia, Remuda’s philosophy is not to use psychotropic medications for either weight gain or weight loss because such use of medication closely resembles the behavior of the eating disorder itself, in which chemical substances are used by patients to manipulate weight and hunger. We do use low doses of mirtazapine on occasion as an augmenting agent to boost the properties of an SSRI, particularly for patients who are not sleeping well at night. However, anorexic patients are often very fearful of taking anything that might cause weight gain. We inform our patients of this side effect and, as a result, have difficulty convincing them to take mirtazapine.

The anticonvulsants are useful for bipolar disorders (as well as severe anxiety and impulsivity). Valproate (Depakote®), gabapentin (Neurontin®), and topiramate (Topamax®) are most commonly used at Remuda Ranch. Depakote® must be monitored with blood tests to watch for anemia and liver changes as well as to assure that the medication remains at a therapeutic blood level. This medication also has the potential for weight gain. Lithium was the drug of choice for many years for bipolar disorders. Although it is an effective medication, in many eating disorder patients it is contraindicated. Lithium is a salt and can easily lead to toxicity for patients who restrict or purge.

Treating Comorbid Anxiety Disorders

Obsessive compulsive disorder (OCD) is seen in many eating disorder patients. If there is a family history of OCD and the OCD was evident prior to the onset of the eating disorder, this diagnosis will be difficult to treat until the patient is fully weight restored and even then it may take up to twelve or more weeks on therapeutic doses of an SSRI to get a partial reduction in symptoms. Of course, a combination of medication and cognitive-behavioral therapy has been shown to be the most effective treatment for patients with OCD.

In combination with SSRIs, some of the atypical antipsychotic medications are also effective in reducing the obsessions and anxiety seen with OCD and in allowing weight restoration. They help to control severe agitation and thought distortions—including body image distortions and hallucinations. At Remuda, we have found olanzapine (Zyprexa®) and quetiapine (Seroquel®) to be useful. These medications work on the dopamine and serotonin systems of the brain. They do have side effects that can cause tremors and muscle spasms, generally in high doses, so it is important to monitor patients on these medications weekly for hints of tremor or muscle rigidity. To reduce the risk of side effects, we generally use low doses of these medications. Unlike the antidepressants, which are generally necessary to take for at least one year of recovery, these medications can often be discontinued once a patient is in recovery.

Patients with a comorbid diagnosis of post traumatic stress disorder are challenging in that they often evidence depression, anxiety, mood lability, self mutilation, dissociation, eating disorder symptoms, obsessive compulsive symptoms, and borderline personality traits. There is no medication or combination of medications that can readily treat all of these symptoms. This is where thorough, careful, multi-disciplinary assessment and diagnosis become paramount to help clarify symptoms and prioritize treatment strategies and goals.

Benzodiazepines, such as alprazolam (Xanax®), lorazepam (Ativan®), and clonazepam (Klonopin®) may be used when necessary with eating disorder patients. Due to addiction potential, benzodiazepines are prescribed for limited reasons—to taper patients off of other benzodiazepines on which they may admit, or for severe panic disorder.

The Psychiatric Provider and the Eating Disorder Treatment Team

Psychiatric providers are most effective when they co-manage eating disorder patients along with other members of a treatment team. Primary care providers offer medical management; registered dietitians assist with weight restoration and nutritional counseling; psychologists may help clarify diagnoses and treatment needs through interviewing and psychological testing; therapists provide individual and group therapy that work synergistically with the psychotropic medications, as well as feedback on the efficacy of medications in symptom reduction; nurses offer milieu management, close medication monitoring, feedback on symptom reduction, and 24-hour patient support that reinforces the therapeutic work offered by the other members of the treatment team.

When trained in the treatment of eating disorder patients and subtleties of differential diagnosis, psychiatric providers can assist the treatment team in determining which symptoms arise from the eating disorder and which from comorbid psychiatric conditions. Psychiatric providers can give other team members insight into what behaviors and conditions may respond to psychotropic medication, and when pharmacological interventions may be warranted. Psychiatric providers can also apprise the team members about when to expect a response to medications and what responses may occur. In addition, psychiatric providers are key to assessing for improvement and decompensation and making decisions about the appropriate level of care for a given patient.

Psychiatric management is one of the foundations for treating the biochemical issues faced by patients with eating disorders. Most patients with eating disorders should be evaluated by a psychiatric provider. Because eating disorders often involve issues across the bio-psychosocial-spiritual spectrum and because each area affects the others, the treatment of patients’ medical needs requires a team approach with open communication among members. In outpatient settings, patients need to sign appropriate releases of information to allow for this effective communication among team members. In inpatient settings, a strongly collaborative team of multi-disciplinary specialists is essential for treatment success.

References

American Psychiatric Association (2000). Practice guideline for the treatment of patients with eating disorders (revision). American Journal of Psychiatry, 157 (Suppl.), 1-39.

Becker, A. E., Hamburg, P., & Herzog, D. B. (1998). The role of psychopharmacologic management in the treatment of eating disorders. Psychiatric Clinics of North America: Annual of Drug Therapy, 5, 17-51.

Blinder, B. J., Blinder, M. C., & Sanathara, V. A. (1998). Eating disorders and addiction. Psychiatric Times, 15, 30-33.

Blinder, B. J., Chaitin, B. F., & Goldstein, R. (1988). Eds. The eating disorders: Medical and psychological bases of diagnosis and treatment. New York: PMA Publications.

Braun, D. L., Sunday, R., & Halmi, K. A. (1994). Psychiatric comorbidity in patients with eating disorders. Psychological Medicine, 24, 859-867.

Bulik, C. M. (2002). Anxiety, Depression, and Eating Disorders. In C. G. Fairburn & K. D. Brownell, Eating disorders and obesity: A comprehensive handbook (pp. 193-198). New York: The Guilford Press.

Gordon, C. M., Dougherty, D. D., Fischman, A. J., Emans, S. J., Grace, E., Lamm, R., et al. (2001). Neural substrates of anorexia nervosa: A behavioral challenge study with positron emission tomography. Journal of Pediatrics, 139, 51-57.

Grilo, C. M., Levy, K. N., Becker, D. F., Edell, W. S., & McGlashan, T. H. (1996). Comorbidity of DSM-III-R axis I and II disorders among female inpatients with eating disorders. Psychiatric Services, 47, 426-429.

Herzog, D. B., Keller, M. B., Sacks, N. R. Yeh, C. J. & Lavori, P. W. (1992). Psychiatric comorbidity in treatment-seeking anorexics and bulimics. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 810-818.

Herzog, D. B., Nussbaum, K. M., & Marmor, A. K. (1996). Comorbidity and outcome in eating disorders. The Psychiatric Clinics of North America, 19, 843-859.

Iwasaki, Y., Matsunaga, H., Kiriike, N., Tanaka, H., & Matsui, T. (2000). Comorbidity of axis I disorders among eating-disordered subjects in Japan. Comprehensive Psychiatry, 41, 454-480.

Mavrogiorgou, P., Juckel, G., & Bauer, M. (2001). Recurrence of paranoid hallucinatory psychoses after beginning a fasting period in a patient with anorexia nervosa. Fortschrift Neurological Psychiatry, 69, 211-214.

Mehler, C., Wewetzer, C., Schulze, U., Warnke, A., Theisen, F., & Dittmann, R. W. (2001) Olanzapine in children and adolescents with chronic anorexia nervosa. A study of five cases. European Child & Adolescent Psychiatry, 10, 151-157

O’Mathuna, D. & Larimore, W. (2001). Alternative medicine: The christian handbook. Grand Rapids, MI: Zondervan Publishing House.

Powers, P. S., Santana, C. A., & Bannon, Y. S. (2002). Olanzapine in the treatment of anorexia nervosa: An open label trial. International Journal of Eating Disorders, 32, 146-154.

Striegel-Moore, R. H., Garvin, V., Dohm, F., & Rosenheck, R. A. (1999). Eating disorders in a national sample of hospitalized female and male veterans: Detection rates and psychiatric comorbidity. International Journal of Eating Disorders, 25, 405-414.

Zaider, T. I., Johnson, J. G., & Cockell, S. J. (2000). Psychiatric comorbidity associated with eating disorder symptomatology among adolescents in the community. International Journal of Eating Disorders, 28, 58-67.

Medical Complications of Eating Disorders

Joel P. Jahraus, MD
Primary Care Medicine
Remuda Programs for Eating Disorders

Abstract. This article discusses the medical complications of eating disorders and the role of the primary care provider in eating disorder treatment teams. The medical complications of eating disorders is a complex topic. This article is an overview based on the existing research and the experience of Remuda’s medical staff in treating 5000 eating disorder patients over the past 13 years. It is intentionally written to be readily understood by the non-medical healthcare provider.

When asked about the consequences of eating disorders, many people think of the emotional devastation and lifestyle disruption that eating disorders cause. Few realize the serious medical complications associated with eating disorders and the risk of significant harm to the body or even death. Psalm 139:13-16 tells us that we are "...fearfully and wonderfully made...". Science confirms what Scripture has long suggested—that the intricacies of human physiology are astounding. Starvation, self-induced vomiting, laxative abuse, and other behaviors associated with eating disorders can completely disrupt the fine tuning of the human body.

In this article, we focus specifically on the medical complications of anorexia and bulimia, including the effects of malnutrition and purging. These symptoms can occur individually or in combination.

Malnutrition

Patients with anorexia, by definition, weigh less than 85% of their medically appropriate weight. Malnutrition is expected in this population. However, malnutrition is often underestimated in patients with bulimia who are at or above normal body weight. The absolute amount and rapidity of weight loss is sometimes more important to the development of medical complications than whether the resultant weight is normal or abnormal for the individual. Weight loss is often perceived as beneficial and individuals may receive positive feedback from friends and others at the same time that their bodies are being compromised by malnutrition.

The relative balance between, and time spent in, bingeing and purging determines weight gain or loss. If bingeing is predominant, such that a significant amount of time is spent bingeing before vomiting, the individual absorbs more nutrients and may evidence stable weight or weight gain. Nevertheless, depending on the content of the binge, malnutrition may still result. For those individuals who spend more time vomiting, weight loss often ensues and malnutrition may eventually be in evidence. It is important to treat each individual separately to best understand the unique impact of the eating disorder on the individual’s physical status.

The primary physical manifestations of malnutrition, particularly evident at low body weight, result from disruption and decrease of the body’s normal metabolism. This is a natural protective mechanism that the body uses, mediated by a change in thyroid hormone production that reduces the body’s caloric requirements.

The maintenance of normal body temperature, pulse, and blood pressure requires a high number of calories. Lowered metabolism leads to a decrease in body temperature with the development of cold intolerance and a progressive drop in pulse and blood pressure. The result is that the individual will often complain of feeling cold, lack of energy, difficulty concentrating, hair loss, constipation, lack of menstrual period, light-headedness, black-out spells, and other symptoms.

Malnourished individuals also change physically over time, with a general diminishment in organ size and function. The heart may lose up to 25% of normal muscle mass, compromising cardiovascular function. The brain decreases in size, as do the uterus, ovaries, and kidneys. A paradoxical fatty replacement of tissue may affect the liver and result in abnormal liver function. Bone deteriorates and osteopenia--a weakening of bone--or osteoporosis ensues. Upon return to healthy body weight, the individual’s organs will usually return to normal size and function. There is insufficient research to determine whether or not the brain is restored. Once bone is lost, most studies show that it does not replenish itself after weight restoration, even with the use of medications such as hormone therapy or calcium and vitamin supplementation. Nevertheless, efforts at preventing further bone loss should be undertaken.

Prepubertal and pubertal children are at particular risk of complications from eating disorders. If the eating disorder strikes during a critical growth period, malnutrition may stunt the child’s growth permanently. Aggressive treatment is warranted. In these cases an ideal weight determination is based not only on the menstrual weight but also on historical information from growth charts. The average weight percentile documented over time in the patient's medical history is extrapolated to obtain an appropriate weight range for the patient’s current age.

Purging

With normal body weight, the physical effects of purging are often not visible. For secretive patients, only the medical provider or dentist may come to suspect that an individual is struggling with an eating disorder.

Although most people equate vomiting with purging, there are other means of purging as well, such as the use of laxatives, diuretics, diet pills, or even compulsive exercise. The individual symptom or combination of symptoms determines the specific physical complications that an individual is likely to face.

For those who vomit, the effects are primarily related to fluid and electrolyte loss (particularly potassium) and local irritation in the mouth, esophagus, and stomach from constant exposure to stomach acid. There may be tears in the stomach and esophagus from the irritation of constant retching. The teeth may deteriorate with the development of cavities or enamel erosion. The salivary glands may swell to accommodate the body’s increased need for digestive salivary juices. Potassium and other electrolyte loss may eventually lead to muscle cramping and even fatal heart rhythm disturbances.

Laxative abuse also leads to fluid and electrolyte loss. It can eventually cause the bowel to lose its normal movement leading to constipation. The continued use of laxatives perpetuates the cycle, continually increasing the individual’s need for laxatives.

A particularly interesting phenomenon exists for those of low body weight who use solely compulsive exercise as their form of purging. In these cases, individuals may be eating what appears to be sufficient calories for their size, yet they continue to lose weight due to the imbalance of calories taken in and calories purged through exercise. The net effect of such weight loss is the same as in pure caloric restriction, but with an additional slowing of heart rate due to the combination of the conditioning effect of exercise and the decreased metabolism related to low body weight.

Refeeding

The process of refeeding can be challenging and may result in medical complications. Individuals with very low body weight are particularly at risk and much care is taken to monitor them in an intensive treatment environment. Daily calories are frequently limited to 800-1200 initially, then advanced over the next few weeks as tolerated. Depending on the degree of malnutrition some of the calories may be given with high caloric supplements either orally or using a feeding tube placed through the nose into the stomach (a "nasogastric tube"). Potential complications include a dilated stomach that loses normal movement (gastroparesis), edema, refeeding hepatitis, and electrolyte imbalances including low phosphorus and magnesium. The heart muscle itself can be weakened from longstanding malnutrition and may be unable to maintain a normal cardiac output resulting in congestive heart failure. Low phosphorus may result in muscle breakdown leading to kidney failure. Vital signs and laboratory values are therefore monitored frequently in addition to daily weights and accurate assessments of intake and output.

In individuals of normal or above normal body weight the degree of malnutrition is often underestimated. In addition, if the individual has vomited frequently or used laxatives or diuretics, sudden abstinence from these behaviors may result in significant fluid retention. Refeeding these individuals often involves starting caloric intake at a slightly higher initial level than those of very low body weight. Careful monitoring is required to avert the potential fluid retention and electrolyte issues.

The next issue of The Remuda Review will offer more details on the refeeding process.

The Primary Care Provider and the Eating Disorder Treatment Team

Primary care providers who see eating disorder patients need to be alert to the medical complications of eating disorders, since patients may not voluntarily seek urgent treatment and their symptoms may go unnoticed for too long. The classic image of the individual of very low body weight, pale and lethargic, bundled up in layered clothing yet refusing to acknowledge her illness, is frequently seen. Occasionally, patients may experience blackouts, chest pain, or even blood in the vomitus, which scare them and lead them to seek medical attention. It is only infrequently, however, that such patients would acknowledge the relationship between their symptoms and malnutrition.

An alert non-medical provider who questions patients about their well-being may help patients to develop a better understanding of how the eating disorder impacts their physical status and to seek medical evaluation. When referring a patient to a primary care provider, it is helpful to provide certain objective information. This includes the patient’s recent physical symptoms, such as weakness, complaints of cold and tiredness, light-headedness, chest pain, apparent weight-loss, swelling of the parotid glands of the face, dental cavities, hair loss, dry skin, and blueness of the hands. It also includes behavioral symptoms, such as extensive dieting; increased isolation; immediate and prolonged trips to the bathroom after meals; increased preoccupation with food, weight, or body image; label reading; calorie and fat gram counting; and frequent weighing.

The primary care provider’s role is to regularly assess and monitor the individual’s physical status and weight and to educate the individual about the medical consequences of eating disorders. The primary care provider also monitors the refeeding process. The frequency of office visits is every week initially with a goal of every other week or eventually monthly after the first two to four weeks, depending on the individual’s response to treatment. Deterioration in vital signs or the development of serious blood abnormalities signifies medical instability and mandates more intensive treatment, typically in an inpatient or residential setting. The primary care provider is instrumental in identifying these medical issues that may necessitate transfer to a higher level of care.

Consistency is important during medical examination, especially when obtaining the individual’s weight. The weight is ideally obtained at approximately the same time of the day, in only a gown and underwear and after voiding. Blood pressure and pulse are obtained in both lying down and standing positions to check for orthostasis, an exaggerated rise in pulse and/or drop in systolic blood pressure which is indicative of malnutrition and/or dehydration. An electrocardiogram is obtained initially along with full blood chemistries to evaluate electrolytes, kidney and liver function, thyroid function, and bone marrow response with a hemoglobin and white blood cell count. A urinalysis is also obtained. Follow-up office visit labs are done if the individual remains entrenched in symptoms with purging and/or low body weight.

Because eating disorders occur in a bio-psycho-social-spiritual context wherein these several dimensions interact dynamically, the primary care provider must also structure treatment to include a multidisciplinary team. In outpatient settings, the team should include at a minimum a dietitian and therapist; often a psychiatrist is needed as well. Patients will need to sign appropriate releases of information to allow for effective communication among team members. Inpatient teams may additionally include nurses, psychologists, and specialty therapists. The primary care provider must play an active role in providing the team with up-to-date medical information communicated in a manner that is understandable to non-medical professionals. The primary care provider must also be accessible to receive communication from other team members, who often have key information about patient symptoms and behaviors. Without this collaborative communication, due to the secrecy that characterizes eating disorders important data can be overlooked. Splitting among team members can also become a serious problem, and a miscommunication about medical status or weight may escalate into a major impediment to the individual’s recovery.

In summation, primary care medicine is an essential component of eating disorder treatment due to the physical devastation associated with eating disorders. Because of these physical consequences, all patients with eating disorders should be evaluated by a primary care provider. Early detection of eating disorders may prevent some of the medical consequences and/or allow for a more complete recovery from these consequences. Healthcare, pastoral, and education professionals can refer to "Signs of an Eating Disorder" in this issue of The Remuda Review to assist in the early identification process. Professionals can refer individuals at risk for eating disorders to a provider who has the specialized training and treatment team in place to assess and address the person’s needs across the bio-psycho-social-spiritual spectrum.

References

Garner, D. M., & Garfinkel, P. E. (1997). Handbook of treatment for eating disorders, 2nd Edition. New York: Guilford Press.

Kaplan, A. S., & Garfinkel, P. E. (1993). Medical issues and the eating disorders: The interface. Levittown, PA: Brunner/Mazel.

Mehler, P. S., & Andersen, A. E. (1999). Eating disorders: A guide to medical care and complications. Baltimore: Johns Hopkins University Press.