Reflections on the Treatment of Eating Disorders
Adair Look, MD
November 15, 2008
New Dawn Eating Disorders Recovery Center
"Emily," a 20-year-old college student, came to treatment just after having attempted suicide by overdosing on pain medications she had found in her parent's bathroom. She admitted that before the attempt, she had become despondent over her unstoppable need to chew large quantities of food and spit it out without ever swallowing any of it. Emily had been chewing and spitting out her food as a way to sooth herself since the sixth grade, but had never been able to tell anyone because she was too embarrassed "Who ever heard of something so gross? I couldn't tell anyone!" she stated.
Emily is one of approximately 5 million people in the United States suffering from an eating disorder, while many more suffer from disordered eating that borders on a full-fledged disorder. In addition, eating disorders carry the highest mortality risk of any psychiatric illness. Patients often come to treatment for reasons seemingly unrelated to their eating disorders. Although there is an overlap in symptomotology, eating disorders are currently categorized into three distinct diagnoses: Anorexia Nervosa (AN), Bulimia Nervosa (BN) and Eating Disorder Not Otherwise Specified (EDNOS). Many patients, like Emily, do not fit neatly into these categories.
"Sarah" was forty-two when she presented to her internist with a concern for chronic halitosis. After an exhaustive medical work-up, Sarah finally admitted to regurgitating her food two to three times per day. After her divorce ten years prior, she began regurgitating her food from stress. She welcomed its soothing effect and that it made her weight easier to manage, so she continued with the behavior despite its inconvenience and its effect on her breath. Sarah's eating disorder, rumination, is far more prevalent than most treaters are aware. Kjelsas shows in his 2004 article that 3% of young women have AN, 8% have BN and about 14% meet criteria for EDNOS. O'Brien (1995) and Fairburn (1984) showed that 17 to 33% of patients with BN engage in rumination at sometime in their history.
Regardless of the commonality of the presenting symptoms, the immediate concerns in treating eating disordered patients include refeeding syndrome, electrolyte abnormalities, and cardiac abnormalities. Refeeding syndrome occurs when patients have starved themselves to the extent that their cardiac tissue has atrophied; when they are then given increased fluids and solids, their heart becomes overloaded. This results in edema, fast heart rate, and abnormal heart beats. These are the common and scary results of malnutrition and can occur in a patient of any weight. Many patients do not realize the severe and life-threatening physical state that they are in, and helping them to seek treatment is essential to their safety.
One aspect of recovery from an eating disorder is effective treatment of other issues that arose prior to or during the onset of the eating disorder. Mood disorders, like depression, are common in most eating-disordered patients, with 73% of patients with AN and in 60% of patients with BN suffering from one or more mood disorder (Herzog 1992). Recent research has focused on the connection between ED and mood, showing that serotonin is involved in modulating impulsivity, obsessionality, mood, and appetite. Patients with bulimia show a decrease use in naturally occurring serotonin and a decrease reactivity to serotonin. Patients with anorexia also show a decrease in serotonin activity and reactivity, but these levels increase after weight recovery has been achieved. Patients are often unaware that SSRIs do not work as effectively on underweight people and that a minimum bodyweight must be achieved for full effect to occur.
Treatment of eating disorders is difficult. However, it is most effective when using a multidisciplinary treatment team including a psychopharmacologist, a therapist, a nutritionist, and a primary care physician. There are currently limited psychopharmacologic interventions for the treatment of eating disorders. Studies show that the use of fluoxitine, desipramine and imipramine are helpful in treating BN (Becker 1998), as is Topamax (Hedges 2003). Anorexia has been more difficult to treat both pharmacologically and therapeutically. Antipsychotics have begun to show promise with abnormal or inaccurate body image issues.
Eating disorders carry with them a stigmatization that makes patients ashamed and secretive of their behavior. It is helpful to encourager patients to see that their illness is a force outside of their person. The disorder itself can be stronger than any one member of a treatment team – but together, the patients and her treaters are stronger. The triumphs of recovery from an eating disorder extend beyond weight stabilization. Sarah has learned other coping mechanisms for stress-relief and healthy weight management, and no longer has bad breath. Emily has been symptom free from both her eating disorder as well as her depression for three years and recently graduated from college with honors, at the top of her class.
Adair Look, MD attended medical school at the University of North Carolina at Chapel Hill. She completed her training in Psychiatry at The Massachusetts General Hospital/Harvard University where she did research and clinical work in the treatment of eating disorders at Harvard University Health Services and at The Massachusetts General Hospital Center for Eating Disorders. After relocating to California, Dr Look was the director of Womens Health for the Department of Psychiatry at California Pacific Medical Center. She now is the Staff Psychiatrist for New Dawn Eating Disorders Recovery Center's Residential Program, and also has a part-time private practice in Santa Rosa, California.
