Laxative withdrawal and anxiety in bulimia nervosa

Yoga as adjunctive therapy in the treatment of people with anorexia nervosa: a Delphi study

BACKGROUND

There is preliminary evidence to suggest that yoga can be beneficial in reducing anxiety, depression and general eating disorder symptoms in people with Anorexia Nervosa (AN). It is unclear whether the therapeutic benefits of yoga are supported or utilised in the treatment of AN amongst clinical experts. The present study aimed to explore and synthesise expert opinion on the use of yoga as an adjunctive therapy in the management of anxiety, depression and over-exercise in individuals with AN.

METHODS

A Delphi methodology was employed, with clinicians considered experts in the treatment of AN recruited internationally to form the panel (n = 18). The first iteration of questionnaires comprised of four open-ended questions concerning the experts' understanding of the term yoga and opinions on its' use in therapy generally and more specifically in the treatment of AN. Using content analysis, statements were derived from this data and included as Likert-based items in two subsequent rounds where panellists rated their level of agreement on each item. Seventeen out of 18 respondents completed all three iterations.

RESULTS

Consensus (level of agreement defined at ≥ 85%) was achieved for 36.47% of the items included in the second and third rounds. The panel reached consensus on items defining yoga and pertaining to its' general benefits. The panel agreed that yoga is a adjunct therapy for various problems, consensus was not achieved on the specific use of yoga as an adjunct therapy in the treatment of comorbid anxiety, depression or trauma in patients with AN. Although the expert panel acknowledged a number of benefits for use of yoga in AN, they strongly endorsed that future research should evaluate the potential risks of using yoga as an embodied practice.

CONCLUSIONS

It is possible that yoga could be considered for inclusion in future guidelines if supported by empirical research. We conclude that there seems to be enough consensus that such further scientific investigation is warranted. This study aimed to explore expert opinion on the use of yoga as an adjunctive therapy in the management of anxiety, depression and over-exercise in individuals with Anorexia Nervosa (AN). Clinicians considered experts in the treatment of AN recruited internationally to form the panel (n = 18). Experts were asked about their understanding of the term yoga and their opinions on its' use in therapy. The panel reached consensus on items defining yoga and pertaining to its' general benefits. Although the panel agreed that yoga is a nice additional therapy for various problems, consensus was not achieved on the use of yoga as an additional therapy in the treatment of specific problems like anxiety, depression or trauma in people with AN. The expert panel acknowledged a number of benefits for use of yoga in AN. However the panel strongly considered that future research should evaluate the potential risks of using yoga as an embodied practice. The areas of collective agreement gained in the study can serve as preliminary guidelines for the use of yoga in AN whilst guiding future research directions.

Controlling the laxative abuse of anorexia nervosa patients with the Serigaya Methamphetamine Relapse Prevention Program workbook: a case report

Background

There is no consensus on effective treatment for laxative abuse in patients with eating disorders. Here, we report the case of a patient with laxative abuse who showed some improvement through an intervention based on the Matrix model.

Case presentation

A woman diagnosed with anorexia nervosa-binge eating/purging type (AN-BP) steadfastly denied laxative abuse and would not admit to suffering from an eating disorder. This led to low motivation for undergoing conventional psychotherapy, psychoeducation, and cognitive behavioral therapy. These were ineffective and followed by repeated cycles of hospitalization and discharge. The patient’s general condition, as depicted by her laboratory and clinical parameters, deteriorated due to the medical complications resulting from laxative abuse.

Focusing on laxative abuse, we considered an intervention for drug addiction. Because the patient could maintain a diet diary and acknowledged laxative abuse as a drug addiction, we introduced the Serigaya Methamphetamine Relapse Prevention Program (SMARPP) workbook as a self-administered treatment. The patient meticulously completed the treatment and experienced a gradual improvement in laxative abuse. She has not been re-hospitalized in 4 years, currently performs household chores, and demonstrates improved social function.

Conclusions

In patients with AN-BP, the SMARPP workbook may be effective in treating laxative abuse.

Gastrointestinal symptoms and disorders in patients with eating disorders

The two most clinically serious eating disorders are anorexia nervosa and bulimia nervosa. A drive for thinness and fear of fatness lead patients with anorexia nervosa either to restrict their food intake or binge-eat then purge (through self-induced vomiting and/or laxative abuse) to reduce their body weight to much less than the normal range. A drive for thinness leads patients with bulimia nervosa to binge-eat then purge but fail to reduce their body weight. Patients with eating disorders present with various gastrointestinal disturbances such as postprandial fullness, abdominal distention, abdominal pain, gastric distension, and early satiety, with altered esophageal motility sometimes seen in patients with anorexia nervosa. Other common conditions noted in patients with eating disorders are postprandial distress syndrome, superior mesenteric artery syndrome, irritable bowel syndrome, and functional constipation. Binge eating may cause acute gastric dilatation and gastric perforation, while self-induced vomiting can lead to dental caries, salivary gland enlargement, gastroesophageal reflux disease, and electrolyte imbalance. Laxative abuse can cause dehydration and electrolyte imbalance. Vomiting and/or laxative abuse can cause hypokalemia, which carries a risk of fatal arrhythmia. Careful assessment and intensive treatment of patients with eating disorders is needed because gastrointestinal symptoms/disorders can progress to a critical condition.

Threat-related attentional bias in anorexia nervosa

OBJECTIVE

Attentional bias (AB) modification treatment targeting general or social anxiety has been recently highlighted as a potential novel approach for the treatment of anorexia nervosa (AN). The purpose of this study was to examine threat-related AB in patients with ANand healthy control participants (HC) and the relationship between AB and eating disorder and other psychopathology.

METHOD

Forty-nine female outpatients with AN or Eating Disorder Not Otherwise Specified, Anorexia Type (EDNOS-AN), and 44 female HC completed a dot-probe task with threat words and a range of self-report measures assessing eating disorder symptoms and other psychopathology.

RESULTS

There was no evidence for a differential threat-related AB in AN patients despite elevated anxiety in this group. The AB-index, a parameter of the magnitude of attention allocation when two competing stimuli are presented, did not correlate with any of the self-report measures. However, patients with AN responded significantly more slowly to the probe as compared to controls, regardless of the valence or position of the stimuli.

DISCUSSION

The results suggest that the AB in AN patients may be specific to eating disorder-relevant anxieties.

The comorbidity between eating disorders and anxiety disorders: prevalence in an eating disorder sample and anxiety disorder sample

OBJECTIVE

To investigate the prevalence of comorbid eating and anxiety disorders in women presenting for inpatient and outpatient treatment of an eating disorder and women presenting for outpatient treatment of an anxiety disorder.

METHODS

The prevalence of comorbidity was investigated from a sample of 152 women, which included 100 women presenting for treatment of an eating disorder and 52 women presenting for treatment of an anxiety disorder.

RESULTS

Of women presenting for treatment of an eating disorder, 65% also met criteria for at least one comorbid anxiety disorder; 69% of these reported the onset of the anxiety disorder to precede the onset of the eating disorder. Of the anxiety disorders diagnosed, social phobia was most frequently diagnosed (42%) followed by post-traumatic stress disorder (26%), generalised anxiety disorder (23%), obsessive-compulsive disorder (5%), panic/agoraphobia (3%) and specific phobia (2%). We also found that 13.5% of women presenting for anxiety treatment also met criteria for a comorbid eating disorder. Furthermore, 71% (n = 5) reported the onset of the anxiety disorder to precede the onset of the eating disorder.

DISCUSSION

The results of this study suggest that the prevalence of eating and anxiety disorder comorbidity is high. The present research should improve the clinical understanding of the comorbidity between eating disorders and anxiety disorders. In particular, it is anticipated that this research will have significant aetiological and therapeutic implications especially with regard to improving the clinical effectiveness of psychological treatments for eating disorders and highlighting the importance of screening for eating pathology in the clinical assessment of anxiety disorders.

Laxative abuse: epidemiology, diagnosis and management

Laxatives have been used for health purposes for over 2000 years, and for much of that time abuse or misuse of laxatives has occurred. Individuals who abuse laxatives can generally be categorized as falling into one of four groups. By far the largest group is made up of individuals suffering from an eating disorder such as anorexia or bulimia nervosa. The prevalence of laxative abuse has been reported to range from approximately 10% to 60% of individuals in this group. The second group consists of individuals who are generally middle aged or older who begin using laxatives when constipated but continue to overuse them. This pattern may be promulgated on certain beliefs that daily bowel movements are necessary for good health. The third group includes individuals engaged in certain types of athletic training, including sports with set weight limits. The fourth group contains surreptitious laxative abusers who use the drugs to cause factitious diarrhoea and may have a factitious disorder. Normal bowel function consists of the absorption of nutrients, electrolytes and water from the gut. Most nutrients are absorbed in the small intestine, while the large bowel absorbs primarily water. There are several types of laxatives available, including stimulant agents, saline and osmotic products, bulking agents and surfactants. The most frequently abused group of laxatives are of the stimulant class. This may be related to the quick action of stimulants, particularly in individuals with eating disorders as they may erroneously believe that they can avoid the absorption of calories via the resulting diarrhoea. Medical problems associated with laxative abuse include electrolyte and acid/base changes that can involve the renal and cardiovascular systems and may become life threatening. The renin-aldosterone system becomes activated due to the loss of fluid, which leads to oedema and acute weight gain when the laxative is discontinued. This can result in reinforcing further laxative abuse when a patient feels bloated and has gained weight. Treatment begins with a high level of suspicion, particularly when a patient presents with alternating diarrhoea and constipation as well as other gastrointestinal complaints. Checking serum electrolytes and the acid/base status can identify individuals who may need medical stabilization and confirm the severity of the abuse. The first step in treating laxative misuse once it is identified is to determine what may be promoting the behaviour, such as an eating disorder or use based on misinformation regarding what constitutes a healthy bowel habit. The first intervention would be to stop the stimulant laxatives and replace them with fibre/osmotic supplements utilized to establish normal bowel movements. Education and further treatment may be required to maintain a healthy bowel programme. In the case of an eating disorder, referral for psychiatric treatment is essential to lessen the reliance on laxatives as a method to alter weight and shape.

Screening Procedure for Detection of Stimulant Laxatives and/or Their Metabolites in Human Urine Using Gas Chromatography-Mass Spectrometry after Enzymatic Cleavage of Conjugates and Extractive Methylation

A gas chromatography-mass spectrometry (GC-MS)-based screening procedure was developed for the detection of stimulant laxatives and/or their metabolites in human urine after enzymatic cleavage of conjugates followed by extractive methylation. The part of the phase-transfer catalyst remaining in the organic phase was removed by solid-phase extraction on a diol phase. The compounds were separated by capillary GC and identified by computerized MS in the full scan mode. By use of mass chromatography with the ions m/z 305, 290, 335, 320, 365, 350, 311, 326, 271, and 346, the possible presence of stimulant laxatives and/or their metabolites could be indicated. The identity of positive signals in such mass chromatograms was confirmed by comparison of the peaks underlying full mass spectra with the reference spectra. This method allowed the detection of the diphenol laxatives bisacodyl, picosulfate, and phenolphthalein and of the anthraquinone laxatives contained in plant extracts and/or their metabolites in human urine samples. The overall recoveries of the stimulant laxatives and/or their metabolites ranged between 33% and 89% with a coefficient of variation of less than 15%, and the limits of detection ranged between 10 and 25 ng/mL (S/N 3) in the full scan mode. After ingestion of the lowest therapeutic dose of sodium picosulfate, its main metabolite, bisacodyl diphenol, was detectable in urine samples for 72 hours. After ingestion of the lowest therapeutic dose of a senna extract, the main metabolite of sennosides, rhein, was detectable in urine samples for 24 hours. This procedure is part of a systematic toxicological analysis procedure for acidic drugs and poisons with the modification of enzymatic cleavage of conjugates.

Nutritional interventions for individuals with bulimia nervosa

Many physical and psychological effects of bulimia nervosa are caused by the patient's partial starvation and chaotic nutritional cycle. Attention should thus be initially directed to correcting nutritional deficiencies and abnormal eating patterns, and providing dietary counselling. Nevertheless, very little has been written about the nutritional management of this eating disorder. Nutritional counselling for bulimia patients is reviewed in this paper. Current knowledge about nutritional therapy and its efficacy, goals and objectives is presented, along with recommendations used in treatment programmes. Lastly, the key steps of nutritional management are summarised.

Detection and importance of laxative use in adolescents with anorexia nervosa

OBJECTIVE

The frequency of laxative use in adolescents with anorexia nervosa is poorly described. This study of adolescents with anorexia nervosa examined self-report and biochemical screening methods for the detection of laxative use, the pattern of laxative use in this population over time, and the associated medical complications and psychopathology.

METHOD

Forty-three consecutive patients with anorexia nervosa were studied. Initial assessment encompassed psychiatric history, medical examination, and administration of the Eating Disorders Examination, Child Behavior Checklist, and Youth Self-Report. Biochemical investigations, including random urinary laxative screening, were performed at assessment and follow-up.

RESULTS

The frequency of laxative use from self-report alone was 12%; combined with urine screening it was 19%. The frequency of laxative use increased to 32% with prospective follow-up. Medical complications were associated with laxative use at follow-up. Laxative use was associated with longer duration of disease and with higher scores on the Eating Disorders Examination subscale Eating Concern.

CONCLUSIONS

Laxative use is common among adolescents with anorexia nervosa, and the risk of associated medical complications increases over time. Biochemical screening will improve detection of laxative use. Longer duration of illness and greater Eating Concern scores are associated with increased risk of laxative use, and monitoring patients at increased risk is important.

Laxative withdrawal in eating disorders: treatment protocol and 3 to 20-month follow-up

OBJECTIVE

This article describes a treatment protocol for laxative withdrawal and presents some preliminary information about response to treatment at 3 to 20-month follow-up.

METHOD

Patients were contacted 3 to 20 months after admission and evaluated with a shortened form of the Eating Disorders Examination (EDE).

RESULTS

Fifty-seven percent of patients were abstinent from laxatives at follow-up and there were significant reductions in laxative-related symptom variables. Abstinence from laxatives was not accompanied by any other changes in eating behavior and was not associated with any pretreatment variables that were assessed.

DISCUSSION

It appears to be feasible to withdraw patients from laxatives as an isolated intervention with a reasonably high rate of success.