Eating Disorders

New Directions in Treatment and Recovery

Barbara Kinoy

• Publisher: Columbia University Press
• Year: 2000
• ISBN:
  9780231502597
• Edition: 2
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Fully revised to reflect changes in the field, this collection of essays by psychotherapists who specialize in the treatment of anorexia nervosa and bulimia explains in accessible and humane terms how the treatment process works and demonstrates strategies that lead to recovery. The book details the interaction between practitioner and patient, practitioner and practitioner, and family members. The collection, which draws upon the knowledge and experience of clinicians who have practiced at the Wilkins Center for Eating Disorders, also points up the advantages of a collaborative team, for both the patient and professionals.

1

Medical Aspects of Anorexia and Bulimia

DIANE W. MICKLEY

Eating disorders involve a complex interplay of physical and emotional factors. The medical complications of anorexia and bulimia can be life-threatening but may give no outward warning symptoms. Attention to health realities must accompany (or even precede) therapy to provide the time and safety for recovery.

ANOREXIA

Most patients with anorexia do not see themselves as starved, since they do eat and often very healthy foods such as salads. But just as a car with the best tires and oil cannot run without gas, no amount of “healthy” foods can make up for inadequate calories. Without sufficient calories, the body slows its metabolism, compromises vital functions like circulation, and destroys muscle to provide the fuel that isn’t coming from food.

The military published a famous study decades ago simulating prisoner-of-war camps by subjecting healthy men to starvation (Keys et al. 1950). Their behavior soon showed many “anorexic” features: They obsessed about food constantly, ate meals slowly and used strange rituals, and felt depressed and tired; once allowed to resume normal eating, they binged for months afterward. Some anorexic symptoms, then, may be understood as a biological defense against starvation. Preoccupation with food, fatigue, and sometimes depression can be tolls of malnutrition alone, which improve when weight is regained.

Patients with anorexia are often plagued by constant thoughts of food and weight. They may experience depression, fatigue, and sleep disturbance, as well as feeling cold, getting bloated or constipated, or growing fine body hair (called lanugo). Many anorexics, however, insist they feel fine, or they minimize their discomforts and continue to work hard, get good grades in school, perform athletically, or exercise compulsively. This makes it hard for patients, family, friends, even doctors, to realize the dangers of their condition.

Not only do anorexic patients perform in a vigorous fashion that may mask the severity of their illness, but the tolls of starvation may not show on a simple physical examination. Electrocardiograms may not show the kind of heart weakening that occurs, and blood tests are often normal or seem only mildly amiss. Because of this, anorexics often insist that they are healthy rather than in jeopardy; others may also be similarly mistaken.

WHEN IS LOW WEIGHT UNHEALTHY

Being underweight takes a major toll on the body. But what is underweight? Anorexics often feel that if other women they know or magazine models can be very thin, then they should be able to be that thin as well. Unfortunately, what seems fair is not always what is healthy. Some lucky individuals maintain a marvelously low cholesterol despite high-fat diets, while others have dangerously high cholesterols even though their diets are ideal. Similarly, people come in many genetically determined body types. A few people have bodies that can tolerate being extremely thin; the vast majority do not.

People inherit many different body types. Efforts to drive weight below biologically predetermined levels result in all sorts of physical and emotional tolls, including loss of menstrual cycles and an intrusive preoccupation with food. In addition, those who exercise frequently or are active athletes increase their percent of muscle mass. Since muscle weighs more, athletes may require weights that are higher than their inactive peers.

A simple formula exists that roughly estimates the ideal weight for a young woman of average bone size, although many women should weigh more than this formula predicts. Take 100 pounds and add 4 pounds for every inch over 5 feet in height (108 pounds for 5 feet, 2 inches; 116 pounds for 5 feet, 4 inches; 124 pounds for 5 feet, 6 inches; and so on). For a more solid build, adjust by adding 5 pounds for every inch over 5 feet (110 pounds for 5 feet 2 inches; 120 pounds for 5 feet 4 inches; and so on). For a very slight bone size, adjust down to add only 3 pounds for every inch over 5 feet (106 pounds for 5 feet, 2 inches; 112 pounds for 5 feet, 4 inches; and so on). Few factors allow for ideal weights lower than these, although a variety of factors (exercise, body type, older ages) result in ideal weights that are higher than these.

The term critical weight defines the minimum weight the body needs for healthy function. Critical weight is about 90 percent of ideal weight. Within 10 percent of ideal weight, as estimated above, some people can be thin but healthy. Below 90 percent of ideal weight, significant physical compromise occurs, even when its tolls are not readily apparent. Thus an average-sized female who is 5 feet, 5 inches, might have an ideal weight of 120 pounds. Her critical weight would then be 10 percent less (that is, 120 pounds minus 12 pounds) or 108 pounds. Critical weight may not be enough for a woman to menstruate or participate in competitive sports, but it gives us a rough guideline of a minimum for adequate health. Below critical weight, major physiological impairment occurs, regardless of how well a person feels.

Two other factors can obscure the impact of dietary restriction. First, youngsters not finished with puberty may not lose weight; they may just get taller without gaining the weight to go along with it. These pre-teens will fail to gain weight and will ultimately stop growing, but they may become anorexic without actual weight loss. Second, girls who are overweight to begin with may lose dangerous amounts of weight and have some of the physical tolls of anorexia but may not seem as dramatically underweight because of the extra pounds they began with.

PHYSICAL TOLLS OF ANOREXIA

As noted earlier, anorexic patients don’t think of themselves as starved, because they do eat some food. Their bodies, however, show the profound effects of starvation. Loss of menstrual periods is one of the most obvious signs of anorexia. Even more dangerous, however, are the invisible tolls of anorexia, especially on the heart, brain, and bones. In a single patient, tests may not demonstrate the severity of physical compromise. However, research studies document the unseen damage.

The impact of anorexia on the reproductive system is reflected in the interruption of menstrual function. Girls who become anorexic in the pre-teen or early teenage years may fail to begin menstruating despite other signs of puberty. They may also miss crucial stages of breast development. Older anorexics stop having menstrual periods unless they happen to be on birth control pills. Interestingly, periods may stop before weight loss occurs for up to one-third of anorexics. Menstruation resumes with adequate weight restoration, but recent data suggest a higher miscarriage rate in women who have had anorexia. Anorexics who are not fully recovered also have a greater incidence of infertility. If fertility treatments are used to induce pregnancy at marginal maternal weights, there is an increased frequency of infants with low birth weights (Abraham, Mira, and Llewellyn-Jones 1990).

Anorexia is associated with a fulminant form of osteoporosis. Lifelong bone strength depends on the accumulation of bone mass during adolescence. With anorexia, bone formation is impaired and bone breakdown is accelerated. This leads to bone thinning, which may be seen within six months of menstrual cessation or with the delayed onset of menstruation in premenarchal girls. It is also seen in young men with anorexia. The osteoporosis of anorexia is typically most severe in the lumbar spine. This can lead to painful fractures, preclude impact exercise (such as jogging), and lead to vertebral compression fractures, which create a stooped posture. Unfortunately, even women who recover fully from anorexia may be left with irreversible osteoporosis. Although low estrogen levels may contribute to the bone loss of anorexia, hormone replacement therapy has not been demonstrated to be of protective value. Nor do the medications that benefit postmenopausal osteoporosis appear to help. The only remedy of proven effectiveness at this time is rapid restoration of weight until menstrual function resumes (Grinspoon, Herzog, and Klibanski 1997).

The tolls of anorexia on the heart are especially dangerous. The body burns muscle to provide fuel as starvation progresses. Heart muscles, like those in the arms and legs, become smaller and weaker. Blood pressure falls, heart rate slows, and the mitral valve may prolapse. To protect vital core organs, the heart reduces circulation to the periphery, visible as acrocyanosis, the bluish-purplish discoloration of the fingers and toes seen in many anorexics, especially in the cold. Cardiac impairment also limits the ability of the heart to increase oxygen delivery to the tissues in response to exercise. Because of this, continued exercise in underweight patients is especially dangerous. Even at rest, however, low weight anorexics are at risk of irregular heart rhythms that can lead to sudden death (Cooke and Chambers 1995).

Anorexia also causes loss of brain tissue, documented by x-ray studies using both Computer-Aided Tomography (CAT scans) and Magnetic Resonance Imaging (MRIs). Cognitive testing shows associated impairment in thought processes. These changes may be subtle, especially initially. With recovery, brain mass appears to improve, at least partially (Swayze et al. 1996).

Stomach function is impaired by anorexia. There is a stomach emptying delay, so food may “sit there,” as it often feels to patients (Kamal et al. 1991). Liquids are more readily digested than solids, and frequent small portions are better tolerated than large meals. Stomach function corrects after months of improved intake, but medication to promote stomach emptying may be useful temporarily if symptoms are severe.

The malnutrition of anorexia has other pervasive effects on health. Bone marrow function may be impaired, interrupting the formation of any line of blood cells. The result is anemia (low counts of red cells that carry oxygen), leukopenia (low counts of white cells that fight infection) and/or thrombocytopenia (low counts of platelets that are needed to stop bleeding). The immune system may be compromised. Levels of thyroid hormone (thyroxine) may fall, cholesterol may rise paradoxically, and liver function may be amiss. Though some patients feel deceptively well, others experience fatigue, coldness, insomnia, constipation, and many other distressing symptoms

Every underweight anorexic is in some degree of danger. Regaining weight is urgent. It is the critical prerequisite both for physical safety and for emotional recovery. Weight restoration may be possible working intensively with an outpatient treatment team that includes not only a psychotherapist but also a physician and dietician experienced in the recovery process for anorexics.

Hospitalization may be necessary if weight is very low (less than 25 percent of ideal body weight), if medical complications arise, or if outpatient weight gain is not immediate (within weeks) and sustained. Inpatient eating disorder programs have been developed at certain psychiatric hospitals. They must be experienced at normalizing weight during hospitalization while developing the skills to maintain weight following discharge. The closer the patient is to ideal weight at the time of hospital discharge, the less likely relapse will occur requiring further hospital admissions. Recent changes in health care have greatly reduced the coverage of full hospital treatment for anorexia. Day programs are now used increasingly, hoping to avert or shorten residential hospital care.

Weight gain is a very difficult process. Patients continue to fear being fat. Minimal increases in calories or volume seem excessive. Exercise often must be stopped temporarily. Psychotherapy and nutritional counseling may provide support and education to foster progress toward a healthy weight. As weight is regained, work in psychotherapy may help patients and families understand and modify stressors that contributed to the illness. However, weight restoration is the initial priority and is essential to preserve health and build a foundation for psychological recovery.

BULIMIA

Anorexia and bulimia sometimes overlap. About 50 percent of patients with anorexia develop bulimic symptoms during their illness. This subset of patients has an especially high incidence of both medical and psychiatric difficulties. The vast majority of patients with bulimia are of normal weight. In fact, up to one-third were overweight in the past.

Bulimics binge; that is, they have episodes of uncontrollable eating, usually consuming large volumes of food. For some, however, binges are subjective; a normal meal or a forbidden food is experienced as excessive. Fearing weight gain, bulimics compensate for their binges. Nonpurging bulimics engage in excessive dieting or exercise. Purging bulimics most commonly induce vomiting. Laxatives, diet pills, or diuretics may also be used in futile attempts to lose weight

Though some patients with bulimia feel well, most experience both emotional and physical discomforts. Bulimics often feel ashamed, secretive, isolated, depressed, out of control. Like anorexics, they are often preoccupied with food and weight in a constant, bothersome way that soon intrudes on other spheres of their lives. Patients with bulimia may also suffer from a wide range of distressing symptoms, including wide weight swings, insomnia, weakness, heartburn, bloating, swollen glands, and irregular periods.

PHYSICAL TOLLS OF BULIMIA

Bulimia can cause pervasive physical damage. Often, however, this is mainly internal and may not produce visible signs. As with anorexia, the physical examination and laboratory tests may be deceptively normal (Becker et al. 1999).

The purging of bulimia usually impacts the gastrointestinal system. Chronic vomiting bathes the esophagus in stomach acid, causing inflammation. Esophageal tears are also common, resulting in pain and the vomiting of blood. The sphincter between the esophagus and stomach becomes impaired, and reflux is common. The stomach empties poorly, producing bloating after meals.

Vomiting depletes the body of potassium and other electrolytes. This danger is compounded by low weight, as well as abuse of diuretics and laxatives. While many bulimics have normal blood tests, electrolytes must be monitored to be safe (Greenfeld et al. 1995). Low potassium may cause muscle weakness, but it can be asymptomatic and still lead to respiratory arrest or irregular heart rhythms, causing sudden death.

Dental problems are rampant in bulimia. Enamel on the lingual surface of the teeth becomes eroded. Cavities and gum disease are common, and patients may lose all their teeth at an early age. Salivary glands in the cheeks (parotids) and lymph nodes under the chin (submandibular) are often enlarged. This can produce swelling and a “chipmunk cheek” appearance, which usually improves once bulimia resolves.

Most patients who abuse laxatives choose the cathartic type. These drugs work for the bowel, causing it to be unable to function on its own after a while. In addition, laxative abuse causes metabolic changes that can lead to painful kidney stones. Very high doses of laxatives that contain phenolphthalein have also been reported to cause pancreatitis and encephalitis. Ironically, using laxatives to lose weight is misguided, since laxatives do not remove calories. Calories are already absorbed before food reaches the part of the colon where laxativ...

Table of contents

• Cover 
• Half title
• Title
• Copyright
• Dedication
• Contents 
• Foreword
• Preface
• Acknowledgments
• List of Contributors
• Disclaimer
• Introduction
• 1: Medical Aspects of Anorexia and Bulimia
• 2: Recovery Through Nutritional Counseling
• 3: Psychiatric Consultation with Eating Disordered Patients
• 4: A Family Systems Perspective on Recovery from an Eating Disorder
• 5: Relationship to Food as to the World
• 6: The Therapeutic Use of Humor in the Treatment of Eating Disorders; or, There Is Life Even with Fat Thighs
• 7: Jodie’s Story
• 8: Eating Disorders and Managed Care
• 9: Cognitive-Behavioral Therapy and Other Short-Term Approaches in the Treatment of Eating Disorders
• 10: The Nurse’s Role in a Pilot Program Using a Modified Cognitive-Behavioral Approach
• 11: Individual Psychotherapy: A Long Journey of Growth and Change
• 12: Young Adult Women: Reflections on Recurring Themes and a Discussion of the Treatment Process and Setting
• 13: Recovery
• Afterword
• Index