Eating
Disorders
Introduction
Eating disorders are abnormal behavior patterns around food intake and body image.
Two of them, anorexia nervosa and bulimia nervosa, affect mainly women. The third
diagnosis of "binge eating disorder" affects men and women equally.
All of these disorders are psychiatric conditions that have been defined in the
Diagnostic and Statistical Manual of Mental Disorders, 4th edition (Ref.1). They
are important to diagnose properly, as failures to do so invariably cause harm.
Anorexia
Nervosa Introduction 95%
or more afflicted with this disorder are young females. The onset is usually during
adolescence. These patients have an abnormal sense of body image, where they think
of themselves as overweight, when they are actually below normal weight. They
are terrified of becoming obese. They refuse to maintain a normal body weight.
In women one of the hallmarks is that they have no menstrual periods (amenorrhea).
All of the body functions are "put on spare flame" and one such function
is the gonadotropin hormone production leading to ovarian malfunction( amenorrhea).
About 1 to 3% of the 15 to 20 year female age group suffer from anorexia nervosa.
There is a significant number of anorexia nervosa cases, where childhood
molestation likely was the triggering factor(see Ref. 2). This study from the
North Dakota School of Medicine and Health Sciences compared the eating behavior
of a group of sexually abused children aged 15 to 20 with a control group of nonabused
children. The study showed that the abused children developed a dissatisfaction
about their weight and in particular they were desiring a leaner body weight.
At times of emotional upsets they would eat less and use methods of purging to
loose even more weight. There are likely other factors such as perhaps a
genetic tendency for depression. Depression, by the way, is present in 85% of
anorexia nervosa patients. This was documented again in a Swedish study (Ref.
3), where 50 teenagers with anorexia nervosa were compared with 51 normal teenagers
as control group. This was a longitudinal study where the same persons were followed
up and intensely interviewed at the ages 16, 21 and 24 years for 10 years. The
findings were that mental illness(mostly depression) was part of anorexia nervosa
and that the outcome of this eating disorder is dictated to a large extent by
how well this is controlled. Conversely, the mental illness cannot be stabilized,
if the anorexia nervosa is not addressed.
Leptin and Restlessness: The
fat cells produce a hormone called leptin, which is produced less when starvation
sets in. Normally a lack of this hormone stimulates the appetite center to increase
appetite. A lack of leptin in the system leads to a restlessness similar to hyperactivity
syndrome. Ref.4 studied this phenomenon in rats as well as in a group of anorexia
nervosa patients. Infusion of leptin in starved rats lead to significant reduction
of a hyperactivity score. Similarly a hyperactivity score in treated anorexia
nervosa patients normalized as the low leptin levels came up to normal levels
with weight gain. It is unclear at this time whether the change in leptins is
part of the cause of anorexia nervosa or whether it is simply another internal
symptom of anorexia nervosa. | Symptoms As
this is mainly a psychological disorder, the earliest symptom is an obsession
about body weight, even when the weight is normal or already below the normal.
Patients may complain about other health problems such as bloating, constipation
or abdominal symptoms. Patients have a normal appetite, but they are preoccupied
with food and diets. They may collect recipes and prepare elaborate meals for
others, but will refrain themselves from eating it. Anorexia nervosa patients
deny that they have a disorder. They also resist treatment. They are often manipulative
and are lying about their true food intake. They are also concealing that they
are inducing vomiting or binge eating followed by vomiting. They also conceal
their use of laxatives(constipation pills) or diuretics(water pills). About 50%
of anorexia nervosa patients have the binge/purge behavior that is typical for
bulimia nervosa patients. Often anorexia nervosa patients engage vigorously in
exercise programs as another means to control weight. Due to hormone changes
there is a loss of sex drive and as I mentioned before a lack of menstrual periods
(called amenorrhea) in females. Other physical symptoms are a slow heart beat,
low body temperature (hypothermia) and low blood pressure. Due to a lack of female
hormones in females there is a male body hair growth pattern and a fine hair growth
all over the body(lanugo hair). Due to a lack of protein there is a development
of edema(water retention in the tissues). Depression as mentioned above is common.
Apart from the above mentioned hormone changes these other hormone changes tend
to occur: low thyroid hormones, low luteinizing hormones, high cortisol levels.
When the body weight is reduced to less than 15% below ideal body weight, virtually
every organ system malfunctions. The most dangerous among these are cardiac disorders
as well as fluid and electrolyte disorders. Heart size and cardiac output decrease.
The induced vomiting and use of laxatives and diuretics leads to severe dehydration
and a metabolic alkalosis. This is diagnosed by blood tests, which show a dysbalance
in the electrolytes and a low potassium level. These electrolyte changes can lead
to dangerous fast irregular heart beat patterns, which will cause sudden death. Diagnosis:
The physician will take a thorough history and ask pertinent questions surrounding
the above mentioned symptoms. The weight that is 15% or more below the ideal body
weight for the person is a powerful pointer as to the diagnosis. However,
other physical conditions such as a brain tumor, Crohn's disease, a hidden cancer
or another mental illness such as schizophrenia has to be excluded by doing appropriate
tests. In females one of the requirements of the diagnosis of anorexia nervosa
is that there are no menstrual periods despite them having been normal in the
past. The hallmark for the diagnosis is the over consuming fear of being or becoming
overweight, which is not diminished by the actual weight loss. Associated with
this condition is the presence of a major depression, which has symptoms of its
own such as sleep disorder, mood disturbance, loss of weight and suicidal thoughts
or behavior. Between cardiac death and death through successful suicide, anorexia
nervosa has a mortality rate of 10 to 20%. Treatment:
This consists of an immediate therapy and a long-term therapy. The first step
is to normalize the body chemistry and induce weight gain well above the cutoff
line of 75% of ideal body weight. This is best done in the hospital setting. Then
there is the long-term therapy consisting of a psychiatric assessment and treatment.
This usually involves behavioral-cognitive and/or psycho-dynamic treatment methods.
If a specialist in eating disorders is available, a referral to that resource
person should be done. Family therapy for younger persons is also helpful,
as the family provides the support when the patient returns to the old environment.
Often family members say exactly the wrong thing, which triggers the patient to
return to the anorexia nervosa behavior pattern. Family therapy addresses that
issue. Often fluoxetine(brand name: Prozac) is used alongside the other psychotherapeutic
treatment modalities. Fluoxetine lifts the depression and helps to control the
phobia associated with eating disorders. It is safe to take this antidepressant
medication for several years until the person has stabilized and adopted healthy
living habits. Contrary to popular believe fluoxetine is NOT addicting.
Bulimia
Nervosa Introduction The
hall mark for this eating disorder is binge eating at least twice per week or
more followed by attempts to reduce the inevitable weight gain. This would include
attempting to vomit and to take water pills and laxatives. It would also
include fasting and over exercising. Bulimia nervosa patients are also overly
concerned about body shape and weight but unlike anorexia nervosa patients bulimia
nervosa patients have usually a normal weight. About 1 to 3 % of young women suffer
from bulimia nervosa. Another 5 to 6% are borderline bulimia nervosa patients.
There is a high percentage of depression among bulimia patients. There seems to
be a certain mental personality make-up before eating binges set in. Several studies
have shown significant differences from controls as follows.
Brain hormones and bulimia nervosa: For
instance, certain brain hormones, called cytokines were 3 times higher in bulimia
nervosa patients when compared to controls(Ref. 5). On the other hand the brain
hormone vasopressin was found to be higher in cerebrospinal fluid(which surrounds
the brain)of bingeing patients with bulimia nervosa or anorexia nervosa. Patients
with major depression showed the same pattern, but not normal controls without
binge behavior or major depression(Ref. 6). Sheppard-Sawyer et al. (Ref. 7) has
shown that disinhibited eating(bingeing) is increased by watching movies that
are sad and that threaten the self esteem of the movie goer. Patients with bulimia
nervosa have a personality make-up where this behavior is triggered easier than
in controls who were not influenced in their eating behavior. This may explain
some of what is going on in the minds of those who are exposed by thousands of
images on TV, in the movies , from magazines and on the Internet that play on
the body image. Bulimia nervosa patients may not have as much resilience as others
and they may act out their subconscious aggressions with bingeing and purging.
Cotrufo et al.(Ref.8) have studied the hormone status of women with bulimia nervosa
and found that the aggressive behavior was directly linked to an increased testosterone
level in the blood stream when compared to controls with normal low testosterone
levels. This difference was significant. | Symptoms The
physical findings of bulimia nervosa patients are mainly due to the result from
purging. Serious fluid and electrolyte disturbances such as low potassium levels
are found in the blood. The self-induced vomiting often has eroded the tooth enamel
of the front teeth. The parotid salivary glands may be swollen because
of an inflammation which leads to narrowed ducts and saliva retention from repeat
vomiting. The longterm abuse of ipecac-syrup, which is used to induce vomiting,
can lead to serious cardiac abnormalities with a heart muscle disease (cardiomyopathy),
hypotension and serious irregular heart beats that can lead to death. These patients
tend to be more talkative and cooperative about their illness than are anorexia
nervosa patients. They are less introverted, but have a tendency to be more impulsive,
to abuse drugs and alcohol and to be depressed. Diagnosis It
may be difficult to diagnose this condition, if the patient does not admit to
frequent bingeing and purging. The official classification demands an average
of binge-purging twice per week over at least 3 months. The physician will attempt
to look for the elements of the various symptoms above and inquire about symptoms
of depression as this frequently coexists. Treatment An
Australian study(Ref.9) has documented that depression and hopelessness have to
be treated first before instituting a cognitive bulimia nervosa program, otherwise
there is a high dropout rate from the treatment program. Another study(Ref.
10) has shown that fluoxetine(brand name: Prozac) is effective in reducing bingeing
and purging, even if there was a failure to psychotherapy treatment. Ref.
11 provides evidence that after 6 sessions of a cognitive therapy program it should
be evident, if the program is working with respect to cutting out bingeing or
not. If the program did not work by then, alternative therapies should be pursued.
However, other literature states that a combination of antidepressant therapy
with Prozac and cognitive or behavioral therapy is superior to either one treatment
modality alone. These treatment modalities can also be combined with the use of
a self hypnosis cassette regarding weight control. Alternative method
fort weight loss / loss of sugar cravings: As part of the accumulation
of weight is due to a craving for sugar, the simple SP6
patch from Lifewave, which has been developed to combat craving for food,
will help you in shedding pounds. This is mentioned in the book "Breakthrough"
by Suzanne Somers (Ref. 17) where newer insights of antiaging medicine are also
reviewed.This is an FDA approved non-drug method and is called "SP6"
because of the name of an acupuncture point. There are no needles involved. Nanotechnology,
a newer technology, is used in the manufacturing of these patches and infrared
(heat) waves from body heat are utilized to energize an acupuncture point, which
in turn normalizes the appetite centre through nerve pathways. For more info follow
the SP6 patch from Lifewave link above (click "products").
Binge
Eating Disorder Introduction This
eating disorder affects both men and women equally and occurs in mainly obese
patients. About 20% of obese patients belong into this category. These patients
take excessive calories in by bingeing, but unlike bulimia nervosa patients they
do not purge. This means that the excessive calories are stored as fat in the
body. Symptoms The symptom of obesity
is easily measurable, but the history of binge eating may be concealed, although
a relative who accompanies the patient may volunteer this, if the patient does
not. There are elaborate questionnaires that can be used to quantitate
the symptoms of overeating and bingeing. It also helps in assessing the severity
of the binge eating disorder. In Ref.12 such questionnaires have been used as
a predictor to the outcome of treatment. This study shows that testing criteria
at the outset were effective in evaluating the severity of the binge eating disorder
and the tests also predicted the success rate of the treatment program. This way
the physician can predict whether a combination of treatment modalities should
be employed or whether a simple cognitive behavioral program would suffice.
Research
findings regarding binge eating disorder: PET scanning
(=positive emission tomography) is expensive and is currently only used as a research
tool or in life threatening clinical situations. In Ref.13 this tool has been
used to document that in a group of women with binge eating disorder there was
an altered blood flow pattern in the brain when their appetite was stimulated
by images of food. There was more blood perfusion in the left hemisphere and the
left frontal lobe of this group compared to normal-weight controls having normal
eating habits. This observation may have far reaching therapeutic significance
for future treatment approaches. | Treatment We
know from literature reviews what the natural history of the disease would be.
For instance, Ref. 14 describes an Oxford University study by Fairburn et al.,
where 150 patients with either bulimia nervosa or binge eating disorder were followed
over a 5-year period without intervention. Patients with bulimia nervosa were
shown to have a poor prognosis with about 40% still having an eating disorder
or obesity after 5 years. In contrast the binge eating disorder group showed a
much better prognosis with a spontaneous cure rate of 80%. A New York study
(Ref. 15)showed that the success rate is higher when a combination therapy program is chosen where fluoxetine (brand
name: Prozac) is used to treat depression and a psychiatric counseling program
is employed to change the long-term attitude towards food and life in general.
This holistic approach appeals both to the patient and the treating physician
and when combined with methods as mentioned in Ref. 12 it is possible to monitor
the treatment success on an ongoing basis. Another method, namely the use
of self hypnosis tapes, can be incorporated with such a combination treatment
approach. Ref. 15 makes the point that an open ended approach is better for the
long-term success, which is the ultimate goal. The physician hopes that a high
percentage of the patients will gradually change their behavior pattern towards
food, become physically more active and change emotionally by conquering depression
and low self esteem. This is a slow process, and it takes a period of trials and
errors coupled with determination and the human factor to truly change body image
and eating patterns. There are new approaches and new weight loss medications,
which will become part of a comprehensive treatment program such as outlined above.
One such newer agent is outlined in Ref.16. This paper shows that the anticonvulsant
medication topiramate (brand name: Topamax) was effective in reducing weight in
a group of patients with binge eating disorder at a dosage of 400 to 600mg daily.
You may want to discuss this with your doctor. If this medication is used, one
has to slowly start the dose and work up to the above mentioned maintenance dose
and at the end of treatment slowly wean the medication to avoid seizures. There
are a number of neurological side-effects, which your doctor could explain to
you. However, any treatment decisions are strictly between you and your doctor.
Just because one study says that a new treatment modality is effective does not
mean that this would be the best treatment in your case. |
