Diagnosis and Treatment of Teens
with Eating Disorders – Part Two
Author: Colleen Symanski-Sanders, RN, Forensic Nurse Specialist
Objectives: Upon the completion of this CNE article, the reader will be able to
- Discuss the diagnostic criteria and differential diagnosis for anorexia nervosa, bulimia nervosa, and binge eating/compulsive overeating.
- Describe the medical complications that can be seen with anorexia nervosa, bulimia nervosa, and binge eating/compulsive overeating.
- Explain the components of assessing and treating anorexia nervosa, bulimia nervosa, and binge eating/compulsive overeating.
This is part two of a three part series. Part one is " The Prevalence and Screening of Teens with Eating Disorders" and Part three is "Athletes and Eating Disorders".
Eating Disorders-The challenge of Diagnosis
Eating disorders are most successfully treated when diagnosed early but are not that easy to diagnose early. Teenagers with eating disorders tend to deny they have a problem when confronted by family, friends, and school professionals or by a physician’s diagnosis. Many anorexics do not receive medical and/or psychological care until they are dangerously thin and malnourished. Bulimic teens can hide their symptoms because they usually have a normal body weight, thereby delaying help until they reach 30 to 40 years of age. For males with eating disorders, early access to treatment is more difficult because anorexia and bulimia are less common; but there is a suggestion that the prevalence of these syndromes in males is increasing. Teens often conceal their symptoms, thus interviews with family members should be part of the assessment. Several other factors complicate the chances of early diagnosis, which include the distrust that teens have of adults and authority figures, a need for privacy, not talking due to fear of revealing vulnerabilities, and fear of parental involvement and punishment.
Important Notes: There is a diagnostic criterion for eating disorders called "not otherwise specified" (or NOS), which excludes anorexia nervosa, bulimia, or binge eating. NOS is not covered in this article. Obesity is also an approved medical diagnosis but is not an eating disorder diagnosis.
Anorexia nervosa dates back to the Middle Ages where it was contemplated whether self-starvation was the work of the devil or God. In 1649 Richard Morton, an English physician gave the illness a place in the medical archives. Dr. Morton described anorexia as "nervous consumption", a complication of a disease such as diabetes or tuberculosis rather than a separate illness. In the early 1870's, a British physician, Sir William Gull, described anorexia nervosa as a separate disease. Sir Gull named anorexia nervosa "nervous loss of appetite". He believed anorexia was caused by a "sick mind"; however, many of his patients were wealthy and were rarely sent to a mental institution. Anorexia and other related eating disorders are now classified as illnesses and have a place of their own in the "Diagnostic and Statistical Manual of Mental Disorders" – Sir Gull was correct.
Based on available statistical information this is what we generally know about the prevalence of anorexia:
- Anorexia nervosa is one of the most common psychiatric diagnoses in young women.
- Between 1% and 2% of American women suffer from anorexia nervosa
- Approximately 90% to 95% of anorexia nervosa sufferers are girls and women.
- Anorexia nervosa typically appears in early to mid-adolescence. It has one of the highest death rates of any mental health condition.
- Between 5% and 20% of individuals struggling with anorexia nervosa will die. The probability of death increases within that range depending on the duration of the illness.
Diagnostic Criteria for Anorexia Nervosa
All of the following are required in order to make a diagnosis of anorexia nervosa.
- Underweight – defined as less than 85% of ideal body weight
- Loss of menstrual periods or menses (in females) – menstruation may occur only following hormone administration
- Extreme fear of gaining weight or becoming fat even though underweight
- Distorted body image or undue influence of body weight or shape on self-evaluation
- Denial of the seriousness of current low body weight
Differential Diagnosis for Anorexia Nervosa
The following must be ruled out in order to make a diagnosis of anorexia nervosa:
- Weight loss associated with a medical condition – and the characteristic features of anorexia such as distortion of body image or an intense fear of getting fat are not evident.
- Bulimia Nervosa – the low weight characteristic of anorexia is not evident.
- Weight loss in depressive disorders – intense fear of getting fat seen with anorexia is not evident. In addition, symptoms of depression
and a loss of interest are present in depressive disorders.
- Schizophrenia – low weight and intense fear of getting fat not evident. In addition, delusions, hallucinations, and/or disorganized speech are usually present in schizophrenia.
- Food obsessions or compulsions in "Obsessive-Compulsive Disorder" – low weight and intense fear of getting fat not evident. Obsessions and compulsions are not restricted to thoughts or behavior about food or weight.
- Social Phobia (avoidance of eating in public) – low weight and intense fear of getting fat not evident.
The Romans engaged in a type of bulimia referred to as "ox hunger" and had "vomitoriums" where men would vomit so they could continue to eat, drink, and be merry. Medical doctors and psychiatrists knew little about bulimia before the 1970’s. A pattern of binge eating and purging was first linked to the advanced stages of anorexia. In 1979, Dr. Gerald Russell was the first to name the disorder "Bulimia Nervosa". He described a bulimic patient by noting "the patient suffers from powerful and intractable urges to overeat; the patient seeks to avoid the ‘fattening’ effects of food by inducing vomiting or abusing purgatives or both; the patient has a morbid fear of becoming obese." Based on available statistical information this is what we generally know about the prevalence of bulimia:
- bulimia nervosa affects 1% to 3% of middle and high school girls.
- Approximately 80% of bulimia nervosa patients are female.
- People struggling with bulimia nervosa will often appear to be of average body weight.
Diagnostic Criteria of Bulimia
All of the following are required for a diagnosis of bulimia nervosa.
- Regular (at least twice weekly) episodes of binge-eating characterized by:
eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time under similar circumstances.
- A sense of loss of control over eating during these episodes (e.g., a feeling that one cannot stop eating or control what or how much one is eating)
- Regular (at least twice weekly) inappropriate compensatory behavior such as self-induced vomiting, laxative or diuretic abuse, fasting, or excessive exercise. The binge eating and compensatory behavior occur twice a week for three months.
- Undue influence of body weight or shape on self-evaluation
There are two types of bulimia, the "purging type" and the "non-purging type". The purging type engages in self-induced vomiting or misuse of laxatives or diuretics. The non-purging type uses other inappropriate compensatory behaviors such as fasting or excessive exercise, but does not regularly engage in self-induced vomiting or misuse of laxatives or diuretics.
Differential Diagnosis for Bulimia
The following must be ruled out in order to make a diagnosis of "bulimia nervosa":
- Vomiting or diarrhea caused by a general medical condition or by excessive substance abuse
- Binge eating in anorexia nervosa
- Overeating in depressive disorders
- Binge eating in Borderline Personality Disorder or Schizophrenia
- Binge eating in Binge Eating/Compulsive Overeating disorder
- Eating disorder "Not Other Otherwise Specified"
Binge Eating/Compulsive Overeating
The eating disorder of "binge eating" is relatively new; therefore, the medical complications, causes, as well as the prevalence are still being studied. Binge eating disorder is also referred to as compulsive overeating. It is characterized by periods of uncontrolled, impulsive, or continuous eating beyond the point of feeling comfortably full. Erratic fasts or repetitive diets may occur but without purging and are followed with feelings of shame or self-hatred. Compulsive overeaters often struggle with anxiety, depression, and loneliness.
Binge Eating Statistics
Available research indicates the following statistics:
- Approximately 25% of obese individuals suffer from binge eating.
- About 60% of individuals with binge eating are females.
- Body weight varies from normal to severe obesity.
Diagnostic Criteria of Binge Eating
- Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
- Eating in a discrete period of time (e.g., within any 2-hour period) an amount of food that is definitely larger than most people would eat during a similar period of time under similar circumstances.
- A sense of lack of control regarding eating during the episode.
- The binge-eating episodes are associated with three or more of the following:
- Eating more rapidly than normal.
- Eating until uncomfortably full.
- Eating large amounts of food when not physically hungry.
- Eating alone out of embarrassment by how much one is eating.
- Feeling disgusted with oneself, depressed, or guilty after overeating.
- Marked distress regarding binge eating is present.
- The binge eating on average occurs at least 2 days a week for 6 months.
- The binge eating is not associated with the regular use of inappropriate compensatory behaviors.
Medical Complications of Eating Disorders
Teens with eating disorders place themselves at risk for anxiety disorders, depression, cardiovascular compromise, chronic fatigue, chronic pain, depression, infectious diseases, insomnia, neurological symptoms, as well as suicide. During self-starvation, as seen in anorexia nervosa, the body is denied the essential nutrients needed to function properly, forcing body systems to slow down in order to conserve energy. This defense mechanism has serious health/medical ramifications. Recurrent binge-and-purge cycles can impact the entire digestive system and lead to electrolyte and chemical imbalances in the body, which can affect the function of the heart and other vital organs. What’s more disturbing, is that even with successful treatment, complications may extend into adulthood such as infertility and poorer health. The chart below identifies many of the complications that can occur with an eating disorder, and although it is extensive, it is not meant to imply an all-inclusive list.
Anorexia Nervosa Medical Complications
Bulimia Medical Complications
1. Cardiac abnormalities and heart failure
2. Dangerously low blood pressure
3. Dangerously low body temperature
4. Growth of lanugo, hair loss, dry hair and nail destruction
5. Low white blood cell count
6. Chronic constipation
7. Osteoporosis due to estrogen loss
8. Loss of menstrual periods and or infertility
9. Muscle wasting, fainting, fatigue, and weakness
10. Severe dehydration can result in kidney
11. Candida albicans infections (yeast infection)
1. Electrolyte imbalances can lead to irregular
heartbeats, heart failure or death. Electrolyte imbalance is caused by dehydration and loss of potassium and
sodium from purging.
2. Dangerously low blood pressure
3. Abnormal menstrual cycles
4. Enlarged parotid glands (salivary gland)
5. Gastric rupture during bingeing
6. Inflammation or rupture of the esophagus
7. Tooth decay and staining from gastric acids
released during vomiting
8. Chronic irregular bowel movements and constipation
9. Peptic ulcers and pancreatitis
10. Dry skin and acne breakouts
11. Candida albicans infections
12. Food allergies
Binge Eating Medical Complications
1. High blood pressure
2. High cholesterol levels
3. Heart disease due to elevated triglyceride levels
5. Gall bladder disease
Assessments of Eating Disorders
A multi-disciplinary approach, which includes a medical history and physical, a nutritional assessment, and a psychological assessment, is necessary for the evaluation of eating disorders. Most treatment centers, hospitals, and professionals use standardized assessment tools based on their preferences such as the ones listed below:
- The Eating Attitudes Test (EAT-26) measures the severity of anorexic symptoms
- The Bulimia Test Revised (BULIT-R) measures the severity of bulimic symptoms
- The Beck Depression Inventory (BDI) measures the severity of depressive symptoms
Laboratory testing is also an essential component of the evaluation. Teens with eating disorders may have normal values; however, abnormal values provide supporting evidence or can point to medical complications rather than an eating disorder. Routine laboratory and diagnostic tests are as follows:
- Amylase – if elevated may indicate possible regular episodes of vomiting
- Bone density testing – evidence of bone loss suggesting mineral deficiencies or ammenorrhea
- Cholesterol – if elevated may indicate possible compulsive overeating
- EKG or Echocardiogram – abnormal rhythms or cardiac function
- Magnesium – if decreased may indicate possible laxative abuse
- Potassium and sodium – if decreased may indicate possible malnutrition, purging, and/or excessive fluid intake
- Urine ketones – if elevated may indicate possible chronic fasting or decreased dietary intake
- Urine specific gravity – if elevated indicates possible dehydration or excessive lack of fluid intake
I have always been curious about the use of the word "treatment" in medicine. There are beauty treatments, hair treatments, water treatments, lawn treatments, and even window treatments – all indicative of action or management aimed at achieving a desired effect. Interesting enough, none of these achieve an everlasting result. There is no "single" treatment for an eating disorder.
Treatment, just as assessment, requires a multi-disciplinary approach due to the complexity of emotional, physiological, and medical problems. Eating disorders have a profound effect on the homeostasis of body function and this balance needs to be restored. It is difficult to treat a teen psychologically and pharmacologically when their body is not in a condition to "listen" or concentrate because of malnourishment. Anorexics in need of a stable weight may have to consume more calories than someone of similar weight and age (who does not have an eating disorder), and consuming calories is exactly what anorexics do not want to do. Some anorexics can guess their "blind" weight just by the sound of the scale. Even normal weight bulimics are vulnerable to weight gain when they consume the required calories. The care/treatment team should consist of:
- A medical physician or nurse practitioner to conduct a physical assessment, laboratory and diagnostic testing, and alcohol and drug screening;
- A nutritionist to assess and advise on nutrition and eating regimens
- A psychotherapist or psychiatrist for immediate and long-term treatment. Psychological counseling must address the eating disorder symptoms AND the underlying psychological, interpersonal, and cultural factors contributing to the eating disorder.
- Group and family psychotherapist,
- Cognitive-behavioral therapy to provide teens with ways to reframe the existing habit (abnormal thoughts and behavior) – this is often one of the most productive forms of treatment because the therapist’s focus is on changing eating behaviors by rewarding or modeling wanted behavior.
- Group therapy has been effective for individuals with bulimia. Caution must be used when sharing "anorexic success stories" as they can sometimes be destructive to treatment (by inducing a feeling of "failure" for those who are still struggling).
- The value of including siblings needs careful evaluation prior to implementation. Excluded siblings may think they are part of the problem; whereas over-bearing /over-protective siblings may be counter-productive.
- A psychopharmacologist to impart expertise about psychoactive medications used to treat eating disorders.
- Antidepressant medications commonly used to treat bulimia include desipramine and imipramine. Fluoxetine has been useful in treating some patients with binge eating disorder as well as any co-occurring depression.
Once a diagnosis of an eating disorder is confirmed the best course of treatment must be developed. If the teen is medically unstable hospitalization is indicated. Criteria for hospitalization include:
- Excessive and rapid weight loss (weight less than 75% of ideal body weight);
- Serious metabolic disturbances – often evident by heart rate less than 45 BPM, change in pulse or systolic blood pressure, or potassium or phosphorus less than 3.0;
- Clinical depression, risk of suicide, or psychosis; or
- Severe binge eating and purging.
Medically stable teens can be treated without hospitalization on an outpatient basis. Teens may elect residential care in an eating disorder center that includes individual, group, and family therapy, along with medical management. Once discharged from an inpatient setting, follow-up is necessary in order to continue to treat underlying issues associated with the eating disorder.
Treatment should also aim at relapse prevention. Cognitive distortions such as denial and rationalization, which occur in eating disorders, make it easier for the teen to set up a relapse episode. These teens need to have new coping skills and be able to implement lifestyle modifications. There is insufficient research regarding the continuities and discontinuities of eating disorders across a person’s life span. This is what we know from short-term outcome data collection:
- Anorexia nervosa has the most severe consequences, with a mortality rate of 0.56% (or about 1 in 180) per year – a rate that is higher than that of almost all other mental disorders.
- Approximately 20% of anorexics will not survive. Fatality is most often due to starvation, suicide, or electrolyte imbalance. The mortality rate from anorexia nervosa is 12 times higher than that for other young women in the population. Many quit treatment, and as many as half will have relapses.
- The severity of the eating disorder as well as body weight are believed to influence the outcome.
- With treatment, about 50% of those with anorexia or bulimia will have a full recovery, 30% will have a partial recovery, and 20% will have no substantial improvement.
The effectiveness of combining psychotherapy and medications continues to be studied by scientists associated with the National Institute of Mental Health. Some of their recent findings showed that group therapy and antidepressant medications combined or alone, benefited patients. For bulimics, the combined use of cognitive-behavioral therapy and antidepressant medication is believed to be the most beneficial. Combination treatment was effective in preventing relapse once medications were discontinued.
The long-term effect of eating disorders on teens and the efficacy of treatments are unknown. What is time-honored is that we must care for and treat the teen and the underlying pathology that is unique for each of them. Collectively, our responsibility is to continue to learn more about these disorders and create a synergy between the diverse clinical management team.
References or Suggested Reading
- American Psychiatric Association. Diagnostic and Statistical Manual for Mental Disorders, fourth edition (DSM-IV). Washington, DC: American Psychiatric Press, 1995.
- Cohen MA. French Toast for Breakfast, Gürze Books, 1995
- DSM-IV-TR Case Studies: A Clinical Guide to Differential Diagnosis, 1st ed., Allen J. J. Frances, Ruth Ross, American Psychiatric Press, Incorporated, September 2001.
- "Eating Disorders Review, November/December 2001. Vl. 12, Number 6
- "Eating Disorders in Males", by Leslie Knowlton, Psychiatric Times, September 1995, Vol. XII, Issue 9
- Gidwani GP, and Rome ES. Eating Disorders. Clinical Obstetrics and Gynecology, 1997;40:601-615.
- Jantz GL. (1995) Hope, Help, & Healing for Eating Disorders, Shaw Publishing, a division of Random House, Inc.
- Johnson JG, Cohen P, Stephanie K, Brook J. Eating Disorders During Adolescence and the Risk for Physical and Mental Disorders During Early Adulthood. Arch Gen Psychiatry. 2002;59:545-552
- Halmi KA, Sunday SR, Strober M, et al. Perfectionism in Anorexia Nervosa: Variation by Clinical Subtype, Obsessionality, and Pathological Eating Behavior,
Am J of Psychiatry 2000;157:1799-1805.
- Keel PK, Mitchell JE, Miller KB, Davis TL, Crow SJ. Long-Term Outcome Of Bulimia Nervosa,
Archives of General Psychiatry 1999:56:63-69.
- Predicting Who may Drop Out of Inpatient Treatment for AN, Eating Disorders Review, November/December 2001, Volume 12, Number 6
- Shives LR. Basic Concepts of Psychiatric-Mental Health Nursing, Fourth Edition, Lippincott-Raven Publishing, 1998.
- Striegel-Moore RH, Wilfley DE, Pike KM, Dohm FA, Fairburn CG: Recurrent binge eating in black American Women. Archives of Family Medicine 2000;9:83-87.
- Zerbe KJ. (1995). The Body Betrayed. Carlsbad, CA: Gürze Books.
- Adolescent Mental Health Issues: ADD, Depression, Suicide, Eating Disorders Volume 3, Issue 2.
- www.NationalEatingDisorders.org, The National Eating Disorders Association.
- www.hedc.org/, The Harvard Eating Disorders Center (HEDC).
Colleen Symanski-Sanders, RN, Forensic Nurse Specialist, has been a Registered Nurse for over 18 years. She has extended her education into forensic nursing, criminal profiling, and psychopathy receiving a Certificate as a Forensic Nurse Specialist. She has over 16 years experience in public health and home care nursing.
Colleen has been an author of educational material for St. Petersburg College, St. Petersburg, Florida. She has also lectured on a variety of topics at numerous nursing symposiums and conferences across the country. She is on the Editorial Board for "Home Health Aide Digest" and "Private Duty Homecare" publications.