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Pierre Leichner

Detecting and Managing Anorexia Nervosa and Bulimia in Adolescents SUMMARY

SOMMAIRE

This paper suggests a diagnostic process for anorexic nervosa and/or bulimia in adolescents. A complete history guided by an understanding of the symptomatology and family conflicts associated with these disorders is the single best tool for their diagnosis. Lengthy investigations are not warranted in most cases. Following an information-giving phase with the patient and her/his family, the treatment plan should be tailored to the patient's individual needs. A biopsychosocial model is suggested consisting of a nutritional rehabilitation program; individual, group and family therapy; and the use of self-help support groups as necessary or available. Working with these patients can be challenging, but rewarding. (Can Fam Physician 1986; 32:2408 -2413.)

Cet article propose un protocole diagnostique de l'anorexie nerveuse et/ou la boulimie chez les adolescents. Une histoire complete inspiree d'une comprehension de la symptomatologie et des conflits familiaux associes 'a de tels desordres est le seul outil efficace pour etablir le diagnostic. La plupart des cas ne necessitent pas de recherches laborieuses injustifiees. Suite a la phase de renseignements offerts au patient et a sa famille, le plan de traitement devrait s'adapter aux besoins de chaque patient. L'auteur suggere un modele biopsychosocial qui comprend un programme de readaptation alimentaire, une therapie individuelle, de groupe et familiale, et la participation de groupes encourageant l'effort personnel lorsque necessaires ou disponibles. Le travail aupres de tels patients constitue un defi et s'avere gratifiant.

Key words: adolescents, anorexia nervosa, bulimia, eating disorders

won~ G _ntnI11111IIII Dr. Leichner is the Director of the Community Psychiatric Centre and of the Eating Disorder Program at the Douglas Hospital in Montreal. He is also the Professional Director of the Anorexia Nervosa and Bulimia Foundation of Canada. Reprint requests to: Dr. P. Leichner, 6875 Lasalle Blvd., Verdun, Que. H4H 1R3

IN A RECENT SURVEY conducted in Manitoba among students aged 12 to 20, 22.3% of females and 5.7% of males gave indications of thoughts and behaviours that have been shown to be associated with anorexia nervosa and/or bulimia.1 ,2 That adolescents are preoccupied with their body and dieting is no surprise. What is alarming, is the high percentage of adolescents who are excessively preoccupied with dieting, and who are using un2408

13-year-old female, straight " A", school athletes from upper socio-economic classes.' It may also develop in students of varying intelligence, age, socio-economic class or race. Illnesses such as diabetes or ulcerative colitis may complicate the picture. The incidence of eating disorders among males may be increasing. Hence the physician should keep these diagnoses in mind for all adolescents entering her or his office. The methods of presentation may vary. Most often the adolescents are brought by other concerned persons. The concern may be about weight loss or evidence of binge-eating and purging. At other times the original complaint may be vague: abdominal pain, episodes of weakness and fainting, or Diagnosis depression. Whatever the method of The demographic profile of an- presentation, two points are worth reorexics and bulimics may be changing. membering. First, these patients tend The illness is no longer affecting only to react in a passive aggressive manner

healthy methods to maintain or reduce their weight. Commonly, patients with anorexia nervosa or bulimia will recall having started their first fast or binge and purge after hearing about it from a schoolmate. What first sounded an attractive way of having their cake and eating it has now become a relentless obsession. For some this obsession may interfere with, or even halt, their psychological or physical development. The family physician has an important role to play in the early detection and management of these disorders. This intervention may prevent the development of a debilitating illness in young people, often of high potential.

CAN. FAM. PHYSICIAN Vol. 32: NOVEMBER 1986

when they are told what to do. Secondly, beneath what may often appear to be a stubbom and defiant personality, there usually lies a low and shaky self-esteem. These are two of the reasons why it is important first to interview the patient alone in a calm and private setting. The approach during the interview should be open, honest and nonjudgemental. Most patients thus approached will answer accurately direct questions about their behaviour. The questions in the history should be based on a sound understanding of the symptomatology of anorexia nervosa and bulimia. Often these patients have read widely about the condition and quickly pick up the uninformed interviewer. They may interpret unfamiliarity with these disorders as a lack of interest and expertise, and then become unco-operative. For brevity, the common symptoms of anorexia nervosa and bulimia are presented in Charts 1 and 2. For anorexia nervosa the key symptom remains the relentless pursuit of thinness, associated with a severe weight loss. Concurrently with this weight loss there develops a fear of weight gain which prevents the patient from retuming to a normal weight despite the supplications of family or other concerned perChart 1

Common Symptoms of Anorexia Nervosa Psychologic Signs * Relentless pursuit of thinness * Refusal to maintain normal body weight * Intense fear of becoming obese by losing control over eating * Dissatisfaction with body shape * Sense of powerlessness over own life situation * High expectations of self and others * Obessive-compulsive personality traits (emphasis on control and

perfection) * "Black or white" thinking * Fear of age, appropriate sexuality, and independence

Behavioural Signs * Restriction of food intake * Unusual eating behaviour * Excessive exercising and/or bulimia, vomiting, laxative abuse, drug abuse * Social withdrawal Note: Reprinted with permission from reference 3. CAN. FAM. PHYSICIAN Vol. 32: NOVEMBER 1986

sons. Anorexics also place great importance on self-control. This is one of the reasons why they have such difficulty in accepting help, which they see as a sign of weakness. The inability to appreciate their wasted appearance, which some anorexics experience, fuels their difficulty in trusting others and their rejection of treatment. It is the same fears of weight gain and loss of-control which drive the bulimic patient into cycles of dieting, binge-eating and purging. Some nosological confusion arises from the fact that binge-eating and purging behaviours are also common among anorexics and obese patients. By definition, however, bulimia refers to a condition that occurs in individuals of normal weight. For uncertain reasons most bulimics do not lose a great amount of weight, or if they do, it is only for a brief period of time.

Part of the medical history should include a detailed description of these patients' daily intake and behaviours. At first, these patients may be unusually vague, but persistent questioning will often reveal that they are on a low-calorie, carbohydrate-free diet and/or use excessive exercise, self-induced vomiting or laxatives to maintain their weight loss or to prevent ex-

Chart 2 Common Symptoms of Bulimia Psychologic Signs . Intense fear of becoming obese by losing control over eating * Dissatisfaction with body shape * Awareness that the eating pattern is abnormal * Depressed mood, particularly following binges * Difficulty controlling impulses Behavioural Signs * Recurrent episodes of binge-eating * Ingesting large amounts of food during binges over a short period of time (up to 5,000 calories per binge) * Binges are carned out secretively * Binges are followed by depressive thoughts and purging obsession * Self-induced vomiting, laxative abuse, excessive exercise or dieting common after binges * No significant or sustained weight loss * Overt self-destructive behavior: Suicide attempts, sexual promiscuity, or substance abuse Note: Reprinted with permission from reference 3.

cessive weight gain. In addition, these patients' views on control and their low self-esteem often lead them towards social withdrawal and depression. The effects of starvation, bingeeating and purging act to worsen these symptoms. The effects of starvation are reviewed in Chart 3. It is important for the physician to know these effects as they may mask the true personality of the patient or mimic other psychopathology. This 'is why the physician should wait until he/she observes a weight gain in the anorexic or a significant normalization in the eating pattern of the bulimic in order to finalize a diagnosis. Phenomenological research in these disorders has given further clues to help in the diagnosis. In most cases the onset of the eating disorder can be linked to a precipitating event. The stressor may be a threat to the patient's self-esteem and sense of control, such as an upcoming separation from friends or family or even, at times, a serious physical illness. Moreover there is increasing evidence that a family history of depression and/or alcoholism and/or an eating disorder in parents, relatives or siblings may be associated with these disorders.4 More

Chart 3 The Toll of Starvation Psychologic and Behavioural Effects * Increased preoccupation with food and food-related behavior * Changed food habits (increased consumpton of spices, coffee, tea or gum) * Increased obsessive-compulsive traits * Emotonal changes, mood lability, anxiety, depression * Decreased concem about health * Decreased sexual interest * Social withdrawal * Binge-eating when food is present Physiologic Effects * Sleep disturbances * Gastrointestinal problems: constipation, bloafing . Hypothermia * Bradycardia . Amenorrhea * Hair loss; increase in lanugo hair * Edema Note: Reprinted with permission from reference 3. 2409

generally, the physician may find in these families high expectations from themselves or others, difficulties in expressing feelings, difficulties with separation, and a high emphasis on physical appearance. Many parents feel bewildered and guilty for what is happening. As with the patient, a calm, forward-looking, educative approach aimed at helping the family to find ways to cope with the anorexic/bulimic member and to improve communications may avoid early resistance. A complete physical examination and a few relevant investigations should follow the preliminary conversation in the interview. The best way to assess the patient's emaciation is to look at her/him stripped to underwear. Physical complications from these eating disorders can affect all body sys-

tems. Table 1 presents a review of the most common complications and the recommended investigations. As the literature on these disorders has exploded, the physician should be careful not to over-diagnose the condition and should consider a complete differential diagnosis. Conditions which ought to be considered are: a brain tumour, an affective disorder, chronic laxative abuse, psychologic vomiting, an obsessive-compulsive disorder, and schizophrenia. Apparently, the most difficult possibility to rule out may be a brain tumour. In particular, tumours in the area of the hypothalamus may mimic the conditions of an eating disorder.5 Although patients suffering from the other conditions may share some of the behaviours or the weight loss of an-

Table 1 Complications of Eating Disorders Most Common System

Most Severe

Cardiovascular

Bradycardia

Arrhythmias

Cardiac failure

Renal

Hypotension Small heart size f Serum urea (BUN)

Glomerular 4 filtration rate

Chronic renal failure

Edema

Gastrointestinal

Constipation Bloating Hypoglycemia

Pancreatitis Chronic pancreatitis Liver disease

Hematologic

Anemia, leukopenia

Electrolytes

Hypokalemia Hypochloremia Reduced growth Erosion of enamel Salivary gland Enlargment + Gonadotropins

Skeletal Dental Endocrine

Cardiac arrest Stunted growth

+ Cortisol * Testosterone (males) 4 Growth hormone

4 Prolactin Neurologic

2410

Seizures Hypothermia

Cerebral atrophy

orexics/bulimics, they tend, as a rule, to lack the relentless pursuit of thinness typical of anorexia nervosa and the exaggerated fear of weight gain typical of both conditions. In addition, patients with these other disorders do not share the same degree of dissatisfaction with, or distortion of, their body image. Finally, as eating disorders may be associated with any physical disorder when the weight loss is out of keeping with the severity of the illness (e.g., ulcerative colitis), or when the management of the illness (e.g., diabetes mellitus) seems unduly difficult, anorexia and/or bulimia should be considered.

Prerequisites for Management

Before considering a management plan, the physician should answer for him/herself three important questions: * First, am I willing to commit the time required to manage the case? The management of anorexic and bulimic Recommended patients can be challenging and time Tests consuming. Although the outcome of treatment is often very rewarding, the Heart Rate physician must be ready to co-ordinate Blood pressure what is, to a large degree, a psychoElectrocardiogram logical intervention. There are no Chest x-ray quick solutions to these problems, and Serum urea, as will be discussed later, pharmacocreatinine therapy, even when appropriate, is only a part of the solution. These patients are quick to pick up frustration in their treaters, and this perception Serum amulase soon makes them feel like failures, SGOT, SGPT Fasting, blood furthering their wish for control and sugar their resistance to treatment. * Secondly, am I comfortable in dealComplete blood ing with power struggles and with pacount and differential tients who do not follow instructions? It is important to keep in mind that the Serum electrolytes responsibility for improvement ultimately lies with the patient, and that she and her family should be involved in finding solutions to her problems. In the more severe cases, when the condition becomes life threatening or is not Serum leutinizing improving, the physician may have to hormone (LH), Follicle take control against the wishes of the stimulating hormone patient and often, with the support of (FSH) the family, hospitalize the patient. Serum cortisol * Thirdly, is there a team of interested health-care professionals available to work with me? In keeping with the bioSerum growth psychosocial nature of these disorders, hormone Prolactin it is important that a management plan be tailored to the individual's needs. The family physician may be needed Body temperature to act as case co-ordinator or, if he/she CAN. FAM. PHYSICIAN Vol. 32: NOVEMBER 1986

and purging several times a day for the ual or family psychotherapy alone will cases should be be successful. Secondly, a multiplicity treated as emergencies for which hos- of approaches may be necessary, and pitalization may be necessary. Infor- the treatment plan should be tailored to mation about the availability of spe- the individual. Pharmacotherapy and cialized treatment programs can be individual, group and/or family therobtained from the organizations whose apy may need to be practised simultaaddresses are appended. neously. Following the history and physical General Prnciples examination, appropriate investigafor the Management tions may be ordered, the patient may of Mild to Moderate Cases be given some relevant reading material about eating disorders, and a reOur understanding of the etiology and management of these conditions turn appointment may be made for a has grown rapidly over this past de- date when all test results are available. cade. The -mortality rate for anorexia As soon as the appropriate diagnostic nervosa, which was believed to be process is completed, a meeting about 25% three decades ago, has de- should be held with 'the patient during creased to between 1 % and 5%.6 One which an appropriate treatment plan Management of Severe Cases of the reasons for this has been the de- should be negotiated. The amount of In either event, I would recommend velopment of a multi-dimensional negotiation or degree of flexibility that the management of severe or treatment approach for eating dis- should depend on the severity of the illness. It might be appropriate to chronic cases of these eating disorders orders.7' 8 A schema of the management plan allow the patient and her family to be referred to mental health-care professionals or to facilities interested in is presented in Figure 1. The following consider the recommended treatment the treatment of these conditions. By are two principles helpful in guiding plan for a period of time before com'severe' cases, I mean persons with the required interventions. First, a plan ing back to give their answer. anorexia nervosa who have been at to correct the biological effects of ex25% below their normal weight for at cessive dietary restraint or binge-eat- Management of least the past six months, or bulimic ing and purging must be implemented Anorexia Nervosa patients who have been binge-eating at the onset. It is unlikely that individOne of the first priorities of the management plan must be a gradual return to an acceptable weight (often Figure 1 on the low side of the normal range). If Management Plan for Anorexia Nervosa or Bulimia a dietitian is available, a consultation may be advantageous to plan the 1st: patient weight-gaining diet. The patient and a o History