658

Conferences and Reviews

Anorexia nervosa and bulimia nervosa are prevalent illnesses affecting between 10/o and 100% of adolescent and college age
women. Developmental, family dynamic, and biologic factors are all important in the cause of this disorder. Anorexia
nervosa is diagnosed when a person refuses to maintain his or her body weight over a minimal normal weight for age and
height, such as 15% below that expected, has an intense fear of gaining weight, has a disturbed body image, and, in
women, has primary or secondary amenorrhea. A diagnosis of bulimia nervosa is made when a person has recurrent
episodes of binge eating, a feeling of lack of control over behavior during binges, regular use of self-induced vomiting,
laxatives, diuretics, strict dieting, or vigorous exercise to prevent weight gain, a minimum of 2 binge episodes a week for at
least 3 months, and persistent overconcern with body shape and weight. Patients with eating disorders are usually secretive
and often come to the attention of physicians only at the insistence of others.
Practitioners also should be alert for medical complications including hypothermia, edema, hypotension, bradycardia,
infertility, and osteoporosis in patients with anorexia nervosa and fluid or electrolyte imbalance, hyperamylasemia,
gastritis, esophagitis, gastric dilation, edema, dental erosion, swollen parotid glands, and gingivitis in patients with bulimia
nervosa.
Treatment involves combining individual, behavioral, group, and family therapy with, possibly, psychopharmaceuti-
cals. Primary care professionals are frequently the first to evaluate these patients, and their encouragement and support
may help patients accept treatment. The treatment proceeds most smoothly if the primary care physician and psychiatrist
work collaboratively with clear and frequent communication.
(Haller E: Eating disorders-A review and update. West J Med 1992 Dec; 157:658-662)

A norexia nervosa and bulimia nervosa are illnesses with eating has been reported in 79% of female college undergrad-
many causes involving developmental, family dynamic, uates, and more than 50% of women in America report that
and biologic factors. Their treatment requires an eclectic, they are dieting.8
individualized approach using a broad range of therapies. Patients with eating disorders are often secretive about
Primary care professionals are often involved in the initial their eating behavior and come to the attention of primary
evaluation and treatment of the symptoms and medical com- care physicians only when others become concerned and
plications of these illnesses. In addition to recognizing the insist on a medical evaluation. Anorexic patients often hide
eating disorder syndrome and treating the medical sequelae, food, abuse laxatives, diuretics, or both, exercise exces-
primary care practitioners have an important role in referring sively, and adamantly deny their symptoms or any need for
patients for psychiatric treatment and in encouraging them to treatment. Patients with bulimia nervosa are even harder to
accept such treatment. * recognize; overt physical changes usually are absent, and
patients often go to great lengths to conceal their behavior.
Diagnosis and Epidemiology Although they are more common in women, both of these
The criteria for diagnosing anorexia nervosa and bulimia disorders also affect men. Approximately 5% to 10% of pa-
nervosa are listed in Tables 1 and 2.1 Over the course of their tients with anorexia nervosa are men, and the disorder may
illness, patients may alternate between anorexia nervosa and be more common in gay men.9' ` The prevalence of bulimia
bulimia nervosa. Of patients who meet diagnostic criteria for nervosa is estimated to be 0.2% of adolescent and young
bulimia nervosa, estimates are that 30% to 80% have histories men, and men represent 10% to 15% of all bulimic patients in
of anorexia nervosa.2 The prevalence of anorexia nervosa is community-based studies.12
estimated to be 1% of young women with a bimodal pattern of
onset; the peaks of onset occur at 13 to 14 and 17 to 18 years Causes of Eating Disorders
of age.3 Bulimia nervosa is more common and affects be- Although many different theories for eating disorders
tween 4% and 10% of adolescent and college-age women.4-7 have been proposed, none appear to be universally true.4
Many women who do not meet the strict diagnostic crite-
ria nevertheless experience some symptoms of eating disor- Development and Family Dynamics
ders such as preoccupations with food and weight.4 Binge As they grow up, anorexic patients often struggle for
*See also "Has Our 'Healthy' Life-style Generated Eating Disorders?" by Joel autonomy, identity, self-respect, and self-control.4"3 An ad-
Yager, MD, on pages 679-680 of this issue. ditional dynamic may be their fear or rejection of adulthood.8
From the Langley Porter Psychiatric Institute, University of California, San Francisco, School of Medicine.
Reprint requests to Ellen Haller, MD, Langley Porter Psychiatric Institute, University of California, San Francisco, School of Medicine, 401 Parnassus Ave, San Francisco, CA
94143.
 - MEDICINE
THE WESTERN JOURNAL OF * DECEMBER 1992 * 157 * 6 659

The families of anorexic patients may be enmeshed, overpro- pared with controls, suggesting a potential dysregulation of
tective, rigid, and poor at resolving conflicts.8 In addition, the satiety mechanism.24
the parents may have high expectations for their children to
succeed and may place pressure on their children to meet Morbidity and Mortality
these possibly unrealistic expectations.14 Anorexia nervosa and bulimia nervosa can have substan-
Bulimic behavior is posited by some authors to service tial morbidity and mortality. Starvation itself disturbs sleep,
unmet developmental needs. For example, Goodsitt pro- impairs concentration, and causes indecisiveness, preoccu-
posed that the behavior reduces tension, helps regulate the pation with food, mood lability, irritability, anxiety, and de-
self, and provides intense stimulation needed to dampen feel- pression. "26 Physical sequelae can include hypothermia,
ings of emptiness."5 Personality traits of low self-esteem, dependent edema, bradycardia, hypotension, and lanugo.
self-regulatory difficulties, frustration intolerance, and an Anorexia nervosa can also lead to infertility, osteoporosis,
cardiac failure, and, ultimately, death.19 Mortality has been
estimated to be about 6% but was 20% in a cohort of patients
TABLE 1.-Diagnostic Criteria for Anorexia Nervoso' observed for 20 years.27'28
* Refusal to maintain body weight over a minimal normal weight for For bulimia nervosa, potential medical complications in-
age and height-for example, weight loss leading to maintenance of clude electrolyte and fluid imbalances, hyperamylasemia,
body weight 15% below that expected-or failure to make expected hypomagnesemia, gastric and esophageal irritation and
weight gain during period of growth, leading to body weight 15% bleeding, gastric dilation, large bowel abnormalities (due to
below that expected laxative abuse), edema, and fatigue.29 Swelling of the parotid
* Intense fear of gaining weight or becoming fat, even though under- glands bilaterally, dental erosion, gingivitis, and knuckle
weight
* Disturbance in the way in which body weight, size, or shape is
calluses (from inducing vomiting using the fingers) are com-
perceived-for example, the person claims to "feel fat" even when mon physical signs of bulimic behavior.
emaciated, believes that one area of the body is "too fat" even when
obviously underweight Prognosis
* In women, the absence of at least 3 consecutive menstrual cycles The prognosis for persons with eating disorders is ex-
when otherwise expected to occur (primary or secondary amenor- tremely variable. Some patients with anorexia may improve
rhea) (A woman is considered to have amenorrhea if her periods without treatment; for others, however, the course can be
occur only following hormone-estrogen-administration)
long and pernicious. After treatment, 50% of patients with
'From the American Psychiatric Association.'
anorexia nervosa may continue having persistent psychoso-
cial impairment, and after achieving remission through suc-
impaired ability to recognize and directly express feelings cessful inpatient treatment, about 50% may relapse within a
(anger in particular) have been described in patients with year.27'30 Authors have concluded that treatment does not
bulimia nervosa.16 Varying degrees and forms of psycho- clearly change the course of anorexia nervosa.28'31
pathology have been described in the families of patients with Despite that bleak conclusion, clinicians can be guided by
bulimia nervosa, such as impaired cohesion, decreased fairly well-defined good-versus-poor prognostic features.
structure, high levels of conflict, and overt negativity. 16 The prognosis for anorexia nervosa is more hopeful if the
patient admits to feeling hungry, has positive self-esteem, is
Neurochemical Changes
Perturbations of the neurotransmitter and neuroendo- TABLE 2.-Diagnostic Criteria for Bulimia Nervosa*
crine systems are seen in persons with anorexia nervosa,
although whether these neurochemical changes precede, ac- * Recurrent episodes of binge eating-rapid consumption of a large
company, or follow the behavioral changes is unclear.17 The amount of food in a discrete period of time
hypothalamic-pituitary-adrenal axis appears perturbed with * A feeling of lack of control over eating behavior during the eating
findings of hypercortisolemia, nonsuppressive dexametha- binges
sone suppression tests, and increased cerebrospinal fluid * Regularly engages in either self-induced vomiting, use of laxatives
(CSF) levels of corticotropin-releasing hormone.18-20 Dis- or diuretics, strict dieting or fasting, or vigorous exercise to prevent
weight gain
ruption of the neuroendocrine system is suggested by the * A minimum average of 2 binge-eating episodes a week for at least 3
finding that 30% to 50% of women with anorexia nervosa months
have amenorrhea before significant weight loss occurs.21 The * Persistent overconcern with body shape and weight
return of menses in these patients is often delayed until some Psychiatric Association.'
'From the American
time after weight is regained.8
A dysregulation of neuroendocrine and neurotransmitter
systems may also play a role in bulimia nervosa. The brain fairly mature developmentally, and has attained some auton-
monamine systems appear to be important modulators of omy.28'32 Poor prognostic features include being ill with the
appetite, mood, and neuroendocrine function, and research- disorder for more than six years, premorbid obesity, bulimic
ers have found increased plasma concentration of 3-endor- behavior, unstable personality, dysfunctional marriage, ex-
phin, decreased plasma concentration of norepinephrine, cessive somatic concerns, and lower minimum weight.33
and decreased CSF levels of the dopamine metabolite, ho- Prognostic features are less well defined for bulimia ner-
movanillic acid, in bulimic patients.22'23 A particularly pro- vosa, but the long-term prognosis appears better than with
vocative finding pertains to alterations in cholecystokinin anorexia nervosa. Most patients have an episodic course with
levels in patients with bulimia nervosa. In a study of bulimic an overall trend toward improvement.28'34'35 A few patients
patients, the cholecystokinin response to a meal and post- with bulimia nervosa are resistant to treatment and have con-
prandial peak levels were found to be decreased when com- tinuous, pernicious courses with extremely poor outcome.28
660
660 EATING DISORDERS
EATING DISORDERS

The prognosis is more hopeful if a patient is motivated for patient are invaluable as this process is planned. Correcting
treatment, does not have concurrent disruptive psychopathol- the starvation state should be done gradually to prevent gas-
ogy, and has good self-esteem.4 36 tric dilation, pedal edema, and possible congestive heart fail-
ure. 8 '0 Establishing an expected rate of weight gain-up to 1
Eating Disorders and Mood Disorders kg (1 to 2 lb) per week-and a final goal weight is useful.
Controversy exists as to the relationship between eating Patients tend to do well initially with several small divided
and mood disorders. Estimates are that 40% to 80% of pa- meals, with a gradual increase in the total amount of calo-
tients with eating disorders meet criteria for a lifelong history ries." Tube feeding should be used only when absolutely
of depression.8 Patients with eating disorders who have histo- necessary because of a life-threatening situation and is rarely
ries of depression tend to have families with histories of required.28
depression. Those without depressive histories themselves
do not appear more likely than controls to have families with Behavioral Treatment
depression.37 Understanding the nature of the relationship One type of psychiatric treatment involves a behavioral
between mood and eating disorders is complicated by the approach that is efficacious, particularly early in treatment.
potential for starvation itself to cause depression and by the With such an approach, patients participate in setting goals
potential for secondary depressions to be brought on by dis- and defining positive reinforcers obtained on achieving these
ruptive life events.38 goals. Positive reinforcers may include, for example, in-
creased autonomy, more privileges, and additional physical
Treating Eating Disorders and social activities.4'"42 Overall, more lenient behavioral
The treatment of eating disorders begins with the comple- programs appear to be as effective as strict programs.43 At
tion of a comprehensive, multidimensional evaluation.4'39 Langley Porter Psychiatric Institute (San Francisco, Califor-
Table 3 lists the areas that need to be addressed in this evalua-
tion.4 Obtaining as complete a history as possible is invalu-
able in planning treatment. In addition, various possible TABLE 3.-Assessing Eating Disorders
medical complications or concomitant psychiatric disorders Assessment Areas to Be Included
must also be ruled out. The goals of treatment include medi- History
cal stabilization, the control of abnormal eating behavior, an Eating disorder ... Eating habits, rituals, behavior
enhanced ability to identify and express emotions, and the Body image
prevention of relapse. Although this discussion focuses on Actual weight, desired weight, minimum and
the overall treatment as provided by psychiatrists and other maximum weights
Use of laxatives, diet pills, diuretics, emetics
ancillary specialists, primary care physicians need a basic Presence of binge or purge behavior
knowledge of the treatment options available to make appro- Menstrual history
priate referrals once an eating disorder is diagnosed. Collab- Use of exercise
oration and close communication between the psychiatrist Psychiatric ....... Include assessment for substance abuse, mood,
and the primary care physician are strongly recommended. anxiety, personality disorders, and suicidality
Past medical .
Anorexia Nervosa Family .......... Both medical and psychiatric
Examination
Inpatient Psychiatric Treatment Mental status .... Suicidality and cognitive status
Although many anorexic patients can be treated as outpa- Physical .
tients, the following criteria have been defined to help clini- Laboratory ....... Complete blood count, electrolytes, blood urea
cians decide whether inpatient psychiatric treatment is nitrogen, creatinine, calcium, magnesium,
phosphate, cholesterol, lipids, amylase, total
needed: protein, albumin, liver function tests, thyroid
* Weight loss greater than 30% of ideal body weight;
function tests, urinalysis, and electrocardio-
gram; consider tuberculin skin test, pituitary
* Persistent suicidal ideation; hormone levels, electroencephalogram, and
* The need for withdrawal from laxatives, diet pills, or chest x-ray film
diuretics; and
* Lack of response to outpatient treatment.39
nia), patients and their primary nurse and therapist create and
Before patients are discharged, they should show an im- sign the written treatment plan that is then incorporated in-
proved ability to monitor diet and weight appropriately, man- to the medical record. The plan is revised regularly as the
age a level of responsibility and activity similar to their home treatment proceeds, with changes made based on a patient's
environment, and to achieve and maintain weight gain. Al- progress.
though in the past patients often required hospital stays of two
to three months to accomplish these goals, the current eco- Individual Psychotherapy
nomic climate of decreased coverage for psychiatric services Individual psychotherapy is a critical adjunct to the be-
has resulted in briefer stays. Therefore, once eating patterns havioral focus, but such treatment is difficult until the starva-
are somewhat stable, patients are often discharged with sub- tion state is at least partially corrected. The technique of
sequent close outpatient monitoring and treatment. psychotherapy involves an empathic therapist who helps con-
tain the patient's overwhelming fears of losing control and
Correction of Starvation State becoming fat.28'3' Patients benefit most from a reassuring,
Primary care professionals can help psychiatrists to man- supportive, and realistic therapist. In the course of the indi-
age appropriately the refeeding of the anorexic patient in a vidual therapy, common themes uncovered include fears of
starved state. Nutritional counseling and education of the failure and of independence, negative self-concepts, a dis-
THE WESTERN JOURNAL OF MEDICINE
WESTERN
THE
JOURNAL
MEDICINE
QE * DECEMBER 1992
, DECEMBER 1992 o 157 o 6 661
661~~~~~~~~

torted body image, an inability or an impaired ability to ing metabolic derangements, and a resolution of acute sui-
identify and express emotion, and a denial of the illness.39 cidality.
Family Treatment Behavioral Treatment
Family therapy may also be recommended by the psychi- The initial goal of treatment is to break or to decrease the
atric treatment team. Families of patients with anorexia ner- binge-purge cycle. Self-monitoring and self-reporting are
vosa may show dysfunctional behavior and interactional key components in establishing a treatment plan. Patients
styles such as overprotectiveness, enmeshment, rigidity, and should participate in identifying specific behavioral goals
poor conflict resolution.44 An active, educational, and often and positive and negative reinforcers. The prescription of
directive therapeutic stance can identify and change the inter- regular eating patterns and of preventing the purge response
actional structure of such families. Goals include providing to eating, coupled with much support and education, are also
mutual support, fostering healthy autonomy, restructuring important components of the treatment plan.49
positions within the family system, and decreasing guilty
feelings.28 Individual Psychotherapy
The initial treatment of bulimia nervosa focuses primarily
Group Therapy on the behavioral and cognitive restructuring techniques nec-
An additional useful method for treating patients with essary to combat a patient's abnormal eating patterns. Other
anorexia is group therapy. Self-help groups with an educa- useful techniques include relaxation training, nutritional
tional focus can assist patients to gain an increased under- counseling, assertiveness training, and supportive psycho-
standing of their illness and to confront their fears of losing therapy. 50 Common themes in the work include improving a
control once they begin to gain weight. Psychotherapeutic patient's low self-esteem, self-consciousness, poor recogni-
group work can lead to a confrontation of intellectualization, tion and identification of feelings, low frustration tolerance,
an improved expression of feelings, and a gradual emergence and poor impulse control.
of increased autonomy and competence.45
Family Treatment
Medications Dysfunctional interactional styles have been described in
Various psychoactive medications have been used to treat some families of patients with bulimia nervosa.8"21 Family
patients with anorexia nervosa, but no single medication has treatment may help to improve the cohesion and structure of
proved to be dramatically effective.28"46 The long-term ef- the family and to decrease the level of conflict. Therapists
fects of the various agents when used in this population are often use an active, educational, and directive style to im-
unknown, and they are best thought of as an adjunct to the prove communication within the family.
therapies already discussed. No real basis exists for the use of
antipsychotic agents unless the patient has concomitant psy- Group Therapy
chotic symptoms.28 Anxiolytics may be useful in reducing Group therapy is also useful. The self-help organization
panic and anxiety associated with fears of losing control and Overeaters Anonymous was founded in 1960 to help persons
gaining weight.4" The mood stabilizer lithium carbonate has with compulsive overeating and now has specialty groups
been reported to show efficacy.48 Because of its potential to focused on issues unique to those with bulimia nervosa. Psy-
cause weight gain-which may adversely affect patient chotherapy groups use an eclectic approach including
compliance-and its possible toxicity in patients who binge cognitive-behavioral, psychoeducational, explorative, and
and purge, lithium should be used with caution in this popu- supportive techniques. Some of the specific techniques sug-
lation. gested include keeping detailed food diaries, learning goal
Antidepressants have not proved to be effective in treating setting, educating patients about the psychology and biology
anorexia nervosa,28 46 but a trial should be considered if de- of bulimia nervosa, and relaxation training.4
pressive symptoms persist despite weight gain or if the pa-
tient has concomitant severe depressive, panic, or obsessive Medications
symptoms.39 If used, antidepressants need to be prescribed Unlike with the treatment of anorexia nervosa, medica-
cautiously at low initial doses with a slow upward titration tions can be useful in treating bulimia nervosa. In general,
because these patients tend to be extremely sensitive to ad- doses should be cautiously determined, the patient should be
verse effects. Vital signs should be closely observed, and, carefully assessed for suicidal ideation, the therapist should
because toxic serum concentrations may develop at relatively be cognizant of the potential for binge-purge behavior to
low doses, levels should be periodically checked.4" exacerbate side effects, and blood levels when available
should be monitored for the particular medication.
Bulimia Nervo; Antidepressants appear to decrease binge-purge behav-
Inpatient Psychiric Treatment ior, improve attitudes about eating, and attenuate the pa-
Most patients w'ih bulimia nervosa can be treated as out- tients' preoccupation with food and weight.5" Several
patients, but active "suicidal ideation, severe depression, double-blind studies have shown notable improvement in pa-
marked electrolyte or fluid imbalance, and the need to be tients treated with antidepressant drugs, but abnormal eating
withdrawn from laxatives, diuretics, emetics, or diet pills are patterns may continue after treatment.52 Antidepressant
all indications for considering inpatient psychiatric treat- drugs studied have included amitriptyline hydrochloride,
ment.28 In addition, resistance to outpatient treatment or mianserin hydrochloride, imipramine hydrochloride, desi-
the failure of such treatment also mandate evaluation for ad- pramine hydrochloride, and phenelzine sulfate.53-58 A recent
mission. Discharge criteria include increased control over review of both open trials and controlled studies with fluoxe-
the abnormal eating behavior, correction of any underly- tine reported notable improvement with this agent as well.59
 662 EATING DISORDERS
ETN IODR

Antidepressants appear to be effective in these patients 25. Garfinkel PE, Kaplan AS: Starvation-based perpetuating mechanisms in an-
orexia nervosa and bulimia. Int J Eat Disord 1985; 4:651-665
regardless of a concomitant diagnosis of depression. In a 26. Keys AJ, Brozek J, Henschel A, Mickelsen 0, Taylor HL: The Biology of
follow-up study of 36 patients, Edelstein and colleagues re- Human Starvation. Minneapolis, Minn, University of Minnesota Press, 1950, pp 575-
586
ported that outcome after treatment with antidepressants was 27. Schwartz DM, Thompson MG: Do anorectics get well? Current research and
not related to Beck depression scale scores.60 Similarly, pa- future needs. Am J Psychiatry 1981; 138:319-323
tients treated with phenelzine were reported to improve sub- 28. Yates A: Current perspectives on the eating disorders: II. Treatment, outcome,
and research directions. J Am Acad Child Adolesc Psychiatry 1990; 29:1-9
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and the presence or absence of depression had no bearing on medical management of bulimia. Ann Intern Med 1987; 107:71-77
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Conclusion 31. Hsu LKG: The treatment ofanorexia nervosa. Am J Psychiatry 1986; 143:573-
581
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predictors of outcome in anorexia nervosa. Br J Psychiatry 1979; 134:71-78
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