Physical illness encountered in patients with eating disorders

Non-interpersonal traumatic events in patients with eating disorders: a systematic review

Objectives

The purpose of the systematic review was to synthesize literature on eating disorders (ED) and non-interpersonal traumatic events (NTE) and consolidate the reported prevalence of NTE in patients with an ED.

Methods

The literature search was performed in Embase, PsycInfo, and PubMed. The keywords in the search were "eating disorder," "trauma" and "non-interpersonal," using index-terms and free-search keywords related to NTE and ED. The PRISMA guidelines were followed. Relevant studies were screened using Rayyan.

Results

Of the 16 studies included in the quantitative synthesis, five overall types of NTE were identified: accidents, illness, injury, natural disaster and war. Findings provided tentative evidence for illness and injury being more prevalent in patients suffering from an ED compared to controls. The remaining subtypes of NTE did not show a higher prevalence in patients with an ED when compared to controls. Findings also suggest that those with binge/purge subtype of anorexia nervosa (AN) had a higher prevalence of non-interpersonal traumatic events compared to the restrictive subtype of AN.

Discussion

This systematic review provided a clear synthesis of previous findings related to NTE among patients with an ED. Noteworthy, is that many studies do not take into account if the trauma happened prior or after to ED onset, which may affect the association. Furthermore, the body of research on NTE in patients with ED is exceedingly limited, and more research is needed.

Liver autophagy in anorexia nervosa and acute liver injury

Autophagy, a lysosomal catabolic pathway for long-lived proteins and damaged organelles, is crucial for cell homeostasis, and survival under stressful conditions. During starvation, autophagy is induced in numerous organisms ranging from yeast to mammals, and promotes survival by supplying nutrients and energy. In the early neonatal period, when transplacental nutrients supply is interrupted, starvation-induced autophagy is crucial for neonates' survival. In adult animals, autophagy provides amino acids and participates in glucose metabolism following starvation. In patients with anorexia nervosa, autophagy appears initially protective, allowing cells to copes with nutrient deprivation. However, when starvation is critically prolonged and when body mass index reaches 13 kg/m(2) or lower, acute liver insufficiency occurs with features of autophagic cell death, which can be observed by electron microscopy analysis of liver biopsy samples. In acetaminophen overdose, a classic cause of severe liver injury, autophagy is induced as a protective mechanism. Pharmacological enhancement of autophagy protects against acetaminophen-induced necrosis. Autophagy is also activated as a rescue mechanism in response to Efavirenz-induced mitochondrial dysfunction. However, Efavirenz overdose blocks autophagy leading to liver cell death. In conclusion, in acute liver injury, autophagy appears as a protective mechanism that can be however blocked or overwhelmed.

Are plasma homocysteine and methionine elevated when binging and purging behavior complicates anorexia nervosa? Evidence against the transdiagnostic theory of eating disorders

OBJECTIVE

To determine whether plasma total homocysteine (tHcy) and plasma methionine levels are different in anorexia nervosa restricting type (AN-R) compared to anorexia nervosa binge eating/purging type (AN-BP).

METHODS

Cross-sectional design.

SUBJECTS

Subjects were recruited from the outpatient program of the Eating Disorders Program at St. Paul's Hospital, Vancouver, Canada. All subjects had a current Diagnostic and Statistical Manual of mental Disorders - Fourth Edition (DSM-IV) AN-R, or AN-BP diagnosis. Controls were recruited from staff and trainees of Child and Family Research Institute, and Children's and Women's Hospital, University of British Columbia.

RESULTS

Samples were obtained from AN-R (N=30), AN-BP (N=32) and control women (N=73) and men (N=33). The 5- 95th% confidence intervals from the control women were taken as the normal range. The plasma tHcy and methionine for the control group had a 5-95th percentile range of 5.66-10.57 and 15.3-40.2 microM, respectively. Plasma tHcy was elevated in women with AN-BP (9.24+/-0.85 microM, N=32) but not with AN-R (7.90+/-0.38 microM, N=30). Plasma methionine was decreased in women with AN-BP (22.2+/-1.43 microM, N=32) compared to the control group of women (25.1+/-0.89 microM). The plasma methionine/tHcy ratio was elevated in the women with AN-BP (0.50+/-0.09) but not in those with AN-R (0.34+/-0.03).

CONCLUSION

Elevated plasma tHcy and decreased plasma methionine are consistent with impaired homocysteine remethylation. Altered methyl transfer capacity or methyl deficiency could impair monoamine neurotransmitter metabolism potentially impacting cognitive and psychological function.We hypothesize that the treatment of AN-BP should consider the need for nutritional support of methyl metabolism.

Haematological changes and iron status in teenage girls with eating disorders and weight loss-the importance of menstrual status

AIM

To study haematological changes and iron stores in teenage girls with eating disorders and weight loss.

METHODS

Blood haemoglobin concentration, white blood cell and thrombocyte count and serum ferritin concentration were measured at assessments of 446 subjects.

RESULTS

Haemoglobin concentrations, leukocyte and thrombocyte counts were related to weight and rate of weight loss but were largely within reference ranges. Serum ferritin concentrations were high in girls with amenorrhea and related to weight and rate of weight loss. Girls who retained menstruations had low serum ferritin concentrations and 37% had depleted iron stores (serum ferritin<16 microg/L).

CONCLUSION

Anaemia, leukopenia and thrombocytopenia are uncommon in teenage girls with eating disorders and weight loss. When present, other diseases causing haematological changes should be considered. In amenorrhoic girls muscle catabolism increases serum ferritin concentrations which may give a false impression of an adequate iron status. This is unmasked in girls with retained menstruations who often have depleted iron stores.

Glucose tolerance predicts short-term refeeding outcome in females with anorexia nervosa

OBJECTIVE

Little is known about biologic predictors of refeeding outcome in anorexia nervosa (AN). Because nutritional status mirrors glucose metabolism during an oral glucose tolerance test (OGTT) in AN, this study investigated whether pretreatment glucose response patterns during the OGTT might be associated with refeeding progress in patients with AN.

METHODS

Sixty-four female patients with anorexia (33 restrictors and 31 binge/purgers) and 13 healthy control subjects underwent an OGTT before nutritional rehabilitation, including desensitization to fear of energy intake of 1000 to 1600 kcal/day. Patients were divided into flat-type responders, impaired glucose tolerance (IGT)-type responders, and normal-type glucose responders. Daily energy intake, weekly weight gain, and the duration of desensitization period were evaluated until the 12th week.

RESULTS

The patients with anorexia consisted of 20 flat-type, 21 IGT-type, and 23 normal- type responders. Normal-type responders required a shorter time to complete the desensitization period than other responders (p = .003 for restrictors, p < .001 for binge/purgers). In terms of refeeding progress, significant group effects for daily energy intake and weekly weight gain were evident in restrictors (p = .006, p = .028, respectively) and binge/purgers (p < .001, p = .003, respectively); normal-type responders showed good refeeding progress compared with other responders in both AN subtypes.

CONCLUSIONS

The present study found a close relationship between pretreatment glucose responses, therapeutic progress of desensitization to fear of energy intake, and refeeding progress in both AN subtypes. Our findings suggest that glucose tolerance may be a useful predictor of short-term refeeding outcome in this disorder.

Insulinogenic index at 15 min as a marker of stable eating behavior in bulimia nervosa

BACKGROUND & AIMS

The aim of this study was to determine the relationship between insulinogenic index at 15 min (II15 min), body weight maintenance, and the presence of vomiting in patients with bulimia nervosa.

METHODS

Forty-eight bulimic inpatients and 14 controls underwent an oral glucose tolerance test on the seventh hospital day. We calculated II15 min and other biological markers, including serum amylase concentrations. During the first week after admission, we monitored the frequency of vomiting and calculated changes in body weight. Patients were divided into 4 subgroups according to the presence of vomiting and weight loss.

RESULTS

Two-factor analysis of variance of the II15 min value revealed significant main effects of vomiting and body weight change (P < 0.001 for both). The II15 min values for controls and bulimic patients with weight loss and no vomiting were lower than those of other bulimic groups. The II15 min values were positively correlated with serum amylase concentrations (r = 0.37, P < 0.01), body weight change (r = 0.35, P < 0.05), and frequencies of vomiting (r = 0.49, P < 0.05).

CONCLUSIONS

These findings suggest that II15 min values may be a useful marker for assessing the stability of eating behavior in patients with bulimia nervosa.

The significance of routine laboratory analyses in the assessment of teenage girls with eating disorders and weight loss

Routine laboratory investigations that had been performed at disease assessment on 327 teenage girls with eating disorders and weight loss were analyzed. The laboratory investigations included erythrocyte sedimentation rate (ESR), blood haemoglobin concentration (Hb), white blood cell count (WBC), platelet count, serum alkaline phosphatase (ALP) activity, serum aspartate aminotransferase (ASAT) activity, serum alanine aminotransferase (ALAT) activity, serum albumin concentration, glycated haemoglobin (HbA1c) and serum concentrations of sodium, potassium, magnesium, calcium (corrected for albumin), inorganic phosphate, creatinine and urea. The results were for ESR, Hb, WBC, platelet count, ALP, ASAT, ALAT, inorganic phosphate, creatinine, urea and HBA1C related to weight and (ongoing) weight loss. The variations of the biochemical measurements were, however, largely within reference ranges, weight and weight changes predicted the biochemical measurements only to a small degree and in individual patients the results of the analyses often suggested normality. These analyses may therefore not be suited to assess the degree of weight loss and starvation in eating disorders. They may, however, be useful for the exclusion of other diseases which could show weight loss and biochemical abnormalities.

Diagnosing bulimia nervosa with parotid gland swelling

BACKGROUND

The authors describe bulimia nervosa, or BN, and its effect on the parotid gland. The associated asymptomatic bilaterally enlarged parotid glands often present a diagnostic dilemma.

CASE DESCRIPTION

The authors present a case of a 22-year-old woman with BN who had bilateral parotid gland swelling, serum electrolyte alteration and no dental stigmata. Her principal concern was the associated cosmetic deformity.

CLINICAL IMPLICATIONS

Because patients with BN who have parotid gland swelling usually are secretive about their purging, the diagnosis may be confirmed by conducting a clinical examination and a serum electrolyte study. Prompt diagnosis can avoid serious medical complications.

Serum electrolytes in bulimic patients with parotid swellings

OBJECTIVE

The purpose of this study was to determine whether electrolyte levels can be used to diagnose bulimia nervosa (BN).

STUDY DESIGN

Four patients with bilateral parotid swellings and BN or suspected BN were examined. Their serum electrolyte levels were retrospectively reviewed.

RESULTS

In this limited study, hypochloremia, hypokalemia, and metabolic alkalosis were present in 1 patient. One patient showed both hypochloremia and hypokalemia, whereas a third patient had only hypochloremia and a low normal serum potassium. The fourth patient demonstrated suspiciously low serum levels of Cl(-) and K(+).

CONCLUSION

Because BN patients tend to be secretive regarding their disorder, serum electrolyte levels may serve as useful tools in diagnosing parotid swellings initiated by bulimia.

A characteristic reactive hypoglycemia induced by rapid change of eating behavior in anorexia nervosa: a case report

The relationship among reactive hypoglycemia, corresponding insulin metabolism, and eating behavior in anorexia nervosa (AN) has not been well documented.

METHOD

A 22-year-old woman with AN was admitted to Kagoshima University Hospital. An oral glucose tolerance test was performed with additional sampling at 15 minutes on the seventh hospital day when her daily caloric intake rapidly increased, reaching 2,000kcal perday.

RESULTS

An elevated level of insulin secretion (1,190pmol/L) was observed during the very early phase (15 minutes) after glucose load, whereas corresponding blood glucose elevations were not as high (1.2mmol/L). The patient experienced asymptomatic hypoglycemia (2.1mmol/L).

CONCLUSIONS

Our findings suggested that a rapid increase of energy intake might cause reactive hypoglycemia with characteristic insulin metabolism, that is, an elevated level of insulin secretion during the very early phase.

Anorexia nervosa medical issues

Anorexia nervosa is an increasingly common chronic psychiatric disorder with a multitude of medical complications. Most of these complications are reversible if there is timely restoration of body weight. A few of them, particularly osteoporosis, refeeding complications, and cardiac arrhythmia, are potentially much more serious. In the end, a multidisciplinary team approach with input from a primary care provider who is familiar with these medical sequelae, together with psychiatric and dietary expertise, can effectuate a successful outcome.

Insulinogenic index at 15 min as a marker of nutritional rehabilitation in anorexia nervosa

BACKGROUND

Insulin responses to the oral-glucose-tolerance test (OGTT) in anorexia nervosa (AN) are related to body weight and show various patterns. Although weight gain is a key indicator of a successful nutritional program, it is not a sufficiently accurate index for assessing nutritional status, especially in the periods of marked fear of obesity, because patients often manipulate body weight measurements.

OBJECTIVE

The aim of this study was to determine the relation between insulin metabolism during the early phase of the OGTT and progress (weekly weight gain) during nutritional rehabilitation.

DESIGN

Forty-eight inpatients with AN (25 AN restricting type and 23 AN bulimic type) underwent the OGTT, with additional blood sampling at 15 min, when energy intake reached 6694 kJ/d (1600 kcal/d). Thirteen healthy volunteers were also studied. To evaluate early-phase insulin metabolism, we calculated the insulinogenic index after 15 (II(15 min)) and 30 min. On the basis of weekly changes in body weight, the AN participants were divided into good (> or =0.5 kg) and poor (<0.5 kg) responders.

RESULTS

Among the AN patients, 48% were poor responders. Analysis of variance showed significant differences in the II(15 min) values (P = 0.0005) and showed that II(15 min) values for good responders were significantly higher than those for the other groups.

CONCLUSIONS

These findings suggest that a lack of progress in weight gain is frequently observed in AN and that II(15 min) values may be a useful marker with which to assess the weekly progress during nutritional rehabilitation.

Laboratory screening for electrolyte abnormalities and anemia in bulimia nervosa: a controlled study

OBJECTIVE

Abnormal eating patterns and recurrent purging behaviors can result in significant medical complications. The purpose of this study was to assess the frequency of abnormalities in clinical laboratory tests in patients with bulimia nervosa who reported being otherwise in good health.

METHODS

Subjects included nonhospitalized women (N = 74) who met criteria for bulimia nervosa outlined in the 3rd Rev. ed. of the Diagnostic and Statistical Manual of Mental Disorders. They also reported use of self-induced vomiting and/or laxatives as compensatory behaviors (purging subtype). The control group (N = 110) included female volunteers with no history of a psychiatric disorder. All subjects reported being in good medical health, were medication free, and were in a normal weight range. Blood samples were analyzed in the hospital clinical laboratory.

RESULTS

Compared with controls, patients showed more frequent occurrence of low values for serum potassium (6.8% vs. 0.9%; p <.05) and chloride (8.1% vs. 0.9%; p <.02). Electrolyte abnormalities occurred most often in patients with frequent bulimic episodes. Study groups did not differ significantly in frequency of abnormal hemoglobin concentrations.

DISCUSSION

These results help to clarify the expected frequency of electrolyte abnormalities in individuals with bulimia nervosa who report otherwise good medical health. The substantial frequency of hypokalemia and hypochloremia underscores the importance of an appropriate medical assessment for individuals with this disorder.

The swallowed toothbrush: a radiographic clue of bulimia

Swallowed toothbrushes were noted in the esophagus of one teenager and the stomach of two others with bulimia. The presence of a toothbrush in the lumen of the gastrointestinal tract should make the radiologist suspicious of bulimia/anorexia nervosa. A toothbrush shows a characteristic radiographic image with parallel rows of short metallic radiodensities due to the metallic plates that hold the bristles in place.

Electrolyte and other blood serum abnormalities in normal weight bulimia nervosa: evidence for sampling bias

OBJECTIVE

Sampling bias due to research settings might be responsible for reported high prevalence rates of electrolyte and serum abnormalities in bulimia nervosa. The aim of this study was to investigate the prevalence of electrolyte and other serum abnormalities in bulimia nervosa patients with normal weight seeking treatment in a community mental health center.

METHOD

Diagnostic evaluations and laboratory tests were done for a consecutive series of 31 patients meeting DSM-III-R criteria for bulimia nervosa.

RESULTS

The duration and clinical severity of the eating disorder were considerable and psychiatric comorbidity was high. None of the subjects showed electrolyte abnormalities. Hypomagnesemia was found in 9.7% and hypoalbuminemia in 6.4% of the population. The severity of the abnormalities was modest.

DISCUSSION

The results suggest that previous reports on electrolyte abnormalities in bulimia nervosa were affected by sampling bias. Based on the results, there is no indication to perform routinely laboratory studies in ambulatory patients with normal weight.

Rapid recovery from anorexia nervosa after a life-threatening episode with severe thrombocytopenia: report of three cases

We report the cases of three patients with anorexia nervosa (AN) who each recovered rapidly after experiencing a life-threatening episode with severe thrombocytopenia. All three cases were the typical restricting-type of AN, occurring in adolescence. They refused to be admitted to a hospital until their general condition had been severely deteriorated. Their lowest platelet counts were 2.9, 4.6, and 2.3 x 10(4)/mm3, respectively. Apparent hemorrhagic tendencies, such as purpura, gingival and nasal bleeding, and gastrointestinal bleeding were observed. The bone marrow examination showed apparent hypoplasia in two patients. No evidence of disseminated intravascular coagulation or autoantibody to platelets was detected. The platelet counts recovered rapidly by water and nutritional supplementation. The recovery from the AN itself was excellent in all three patients without specific psychotherapy.

Blood pressure-related hypoalgesia in bulimia nervosa

OBJECTIVE

This study examined pain sensitivity and its relationship to arterial blood pressure in bulimia nervosa (BN).

METHODS

Fourteen women who met Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, criteria for BN, purging subtype, and 14 controls were tested for ischemic pain sensitivity after an extended baseline period. Blood pressure, cardiac output, stroke volume, and total peripheral resistance were assessed during baseline, during ischemic pain testing, and at the point of voluntary tolerance.

RESULTS

Women with BN had significantly greater ischemic pain tolerance than controls. Additionally, only for BN women was blood pressure related to pain sensitivity. Systolic blood pressure during the pain procedure and at the point of tolerance was positively related to pain threshold and tolerance times and negatively related to rated unpleasantness of pain in BN, whereas no relationships involving blood pressure and pain sensitivity were observed in controls.

CONCLUSIONS

These results may have implications for maladaptive changes in central pain-cardiovascular regulatory systems for women with BN.

Serotonin syndrome due to venlafaxine overdose

A case is presented of serotonin syndrome after deliberate overdose of the antidepressant venlafaxine. The mechanism, diagnosis, and management of this disorder is discussed.

Life threatening airway obstruction: a hazard of concealed eating disorders

The ingestion of unusual objects is not uncommon in florid mental illness. Less common is the accidental ingestion of a foreign body which has been used to induce vomiting. A case is reported of complete dysphagia that resulted from impaction of a plastic fork in the hypopharynx. The patient had been attempting to induce vomiting and, as a result of the presentation, was found to be suffering from a previously concealed eating disorder (bulimia). Self induced vomiting is one criterion for the diagnosis of bulimia and a review of the literature indicates that accidental ingestion of large foreign bodies is an increasingly familiar hazard of occult bulimia.

The evaluation of eating and weight symptoms. A comparison of medically ill and eating disorder patients

The purpose of this study was to determine the utility of hospitalization in a medical-psychiatry unit for eating disorder patients. A retrospective chart review of 48 patients given an International Classification of Disease-9 diagnosis of an eating disorder was conducted. Presenting symptoms, functional status using the Karnofsky Index, medical and psychiatric evaluation, diagnosis, treatment, and outcome were evaluated. Patients fell into 1 of 3 groups: those with an active eating disorder and comorbid medical complications (Eating Disorder [ED] positive [POS], n = 25), those with a history of an eating disorder admitted for some other reason (ED history [HX], n = 8), and those with eating or weight symptoms ultimately found to be related to a noneating disorder or primary medical process (ED negative [NEG], n = 15). The ED POS patients were younger (28.1 vs. 49.1 years, P = 0.0001) but had a lower functional status on admission compared with the ED NEG patients (Karnofsky score 51 vs. 72, P = 0.0002). They were more likely to binge eat, restrain intake, and abuse laxatives (P = 0.0001, P = 0.024, P = 0.037, respectively) but did not differ with respect to history of vomiting (P = 0.113). The ED POS patients were more likely to be transferred to a general psychiatry or eating disorder unit. Overall length of stay was greater in this group (44.6 vs. 20.4 days, P = 0.031). Initial evaluation of patients presenting with eating or weight symptoms may be difficult given similarities between the patients with primary eating disorders and those with other underlying medical causes. The medical-psychiatry unit provides comprehensive initial evaluation and treatment of patients with eating and weight symptoms.

The evaluation of eating and weight symptoms in the general hospital consultation setting

Eating disorders (ED) in the medically ill population have seldom been studied. The objective of this study is to review a series of medical and surgical patients referred for psychiatric evaluation for a presumed ED. Between 1982 and 1990, a series of 65 patients were referred for psychiatric consultation to evaluate for an ED. All patients records were reviewed for demographic, medical, and psychiatric information, including medical course following the consultation. Sixty-three percent of the study population were referred by internal medicine services. The most common presenting symptoms were self-induced vomiting (39.1%), binge eating (34.4%) and weight loss (31.3%). Bulimia nervosa (n = 21), anorexia nervosa (n = 19), and no psychiatric diagnosis (n = 18) were the most frequent diagnoses. Record review suggested significant challenges to accurate eating disorder diagnoses in patients presenting with primary medical complaints.

Eating disorders. Guide to medical evaluation and complications

Eating disorders lead to numerous physical complaints with signs and symptoms affecting nearly every organ system of the body. We review the presentation of a patient with eating disorder to the primary care giver or general psychiatrist, focusing on the physical manifestations of the underlying illness. Specific complications related to laboratory findings, the gastrointestinal tract, and the endocrine system are reviewed. Algorithms for medical evaluation of these patients are also presented.

Defining subgroups of dieting disorder patients by means of the Eating Disorders Examination (EDE)

BACKGROUND

It is important to determine the optimal manner of categorising eating disorder patients so as to aid in the understanding of their specific psychopathological state.

METHOD

We compared subgroups of eating disorder patients divided according to different sets of factors, using a structured interview which elicits the specific psychopathological features of these illnesses. The patients, comprising 116 consecutive women admitted to two university-affiliated eating disorder clinics, were grouped according to DSM-III-R criteria, clinical presentation (purging, binge eating), nutritional status, and age.

RESULT

The clearest separation of groups was afforded by the clinical dimension of purging as opposed to not purging. This was superior to DSM-III-R criteria. Other systems, such as presence of binge eating, and various levels of nutritional status and of age, were clearly inferior.

CONCLUSION

The presence or absence of purging behaviour appears to offer the most heuristic means of categorising eating disorder patients with respect to their specific psychopathological state.

Eating disorder patients at a NSW teaching hospital: a comparison with state-wide data

The aim of the study was to present data which may be useful in deciding the type of services needed for eating disorder (ED) patients in New South Wales (NSW). The demographic and clinical characteristics of 155 patients consecutively admitted to a special ED unit at a major Sydney teaching hospital during the triennium 1989-1991 were documented and compared with relevant data from the State as a whole (709 admissions for ED to public facilities and 938 admissions for ED to private facilities during the same period). The findings are discussed in the light of information from overseas studies. Although a relatively large number of ED patients are admitted to hospitals in NSW, their short duration of stay suggests that many may receive inadequate treatment. The unit in the Department of Psychiatry at the Royal Prince Alfred Hospital (RPA), the largest public ED service in NSW, provides a special service for these patients. It is effective in bringing about nutritional restoration, with a duration of stay similar to those reported from centres overseas. Most referrals are tertiary, and there is a high prevalence of physical morbidity indicating a need for access to general medical facilities. Most serious physical complications occur in patients who can be identified by their chronicity and by the pattern of their behavioural disturbance. These various factors are considered in the formulation of recommendations for rationalizing the service.

Anorexia nervosa and tuberculosis: case reports and a review of immune mechanisms

A pair of identical twins living together and with a long-standing history of anorexia nervosa were admitted to restore weight. In the course of their admission one of them was found to be suffering from pulmonary tuberculosis and the other developed tuberculosis after 1 year. We seek to highlight factors that can lead to a delay in case detection and discuss issues relating to the immune mechanisms in tuberculosis and anorexia nervosa.

Excessive physical activity in dieting disorder patients: proposals for a supervised exercise program

A relationship between starvation and hyperactivity has been observed in animal models, in experiments with human subjects, and in dieting disorder patients. Since the earliest descriptions of anorexia nervosa, excessive physical activity has figured prominently as a symptom of the illness, yet little attention has been directed towards this phenomenon. The aims of this paper are to review the published literature, to report our experience of the role of physical overactivity in the clinical presentation of dieting disorders, to discuss its implications for treatment, and to propose a supervised exercise program by which overactivity may be addressed specifically in the treatment of these patients.

The medical complications of anorexia nervosa

The physical complications of anorexia nervosa are common and can be life threatening, but psychiatrists and the increasing number of non-medical therapists involved in treatment programmes often overlook these complications. Cardiovascular complications are the most common, and the most likely to result in fatalities, particularly in those patients who vomit, purge or abuse diuretics, because of the electrolyte abnormalities induced. Osteoporosis is an early and perhaps irreversible consequence of severe weight loss. Further, there are dangers in rapid intravenous hyperalimentation.

Bulimia nervosa. Four uncommon subtypes

The histories and psychological profiles of more than 500 patients meeting DSM-III-R criteria for bulimia nervosa were reviewed. A total of 310 patients demonstrated the most characteristic pattern of bulimia, with finger-induced purging and occasional diet pill, diuretic, or laxative abuse. Seventeen patients reported binge eating with no self-induced vomiting but with severe laxative abuse (i.e., greater than or equal to 50 laxatives daily). A total of 126 patients reported bulimia with finger-induced purging and regular mild (i.e., 2-3 daily) laxative abuse. Eight patients reported bulimia without finger-induced purging, diuretic, or laxative abuse but with the regular abuse of ipecac as a means of inducing vomiting. Four clinical subtypes of bulimia were seen. These were overt bulimia, which occurred in 8.9% of the sample; obsessive-ritualistic bulimia, which occurred in 2% of the sample; sexually evocative bulimia (Fatal Attraction Syndrome), which occurred in 2.9% of the sample; and masochistic bulimia, which occurred in 4.9% of the sample. Each of these subtypes of bulimia are described and defined. The characteristic psychologic profile, clinical features, and implications for treatment and research are discussed.

Hypophosphataemia, delirium and cardiac arrhythmia in anorexia nervosa

OBJECTIVE

To draw attention to the occurrence of hypophosphataemia in anorexia nervosa and to suggest that it may be a factor contributing to cardiac arrhythmia, a potentially fatal complication.

DESIGN

A retrospective study of patients under the consultant care of one of us. All were adolescent girls or young women aged 14 to 31.

CLINICAL COURSE

During the index admission, three became acutely hypophosphataemic while receiving saline and potassium intravenously to correct hypokalaemia. Four patients were subsequently treated with phosphate supplementation. Two patients died, and three recovered.

CONCLUSION

Hypophosphataemia in anorexia nervosa patients may play a role in the development of cardiac arrhythmia and delirium.

Eating disorders and intentional insulin undertreatment in adolescent females with diabetes

Intentional undertreatment with insulin was found to be a common method of inducing weight loss or preventing weight gain in female adolescents with insulin-dependent diabetes mellitus (IDDM) and eating disorders. More than half of those with eating disorders intentionally omitted insulin to produce hyperglycemia and weight loss. Individuals with eating disorders were also less compliant with other aspects of IDDM management and had poorer metabolic control than the rest of the sample. It is suggested here that intentional undertreatment with insulin in some individuals with IDDM may be regarded as an equivalent to purging, with similar purpose and consequences.

Biomedical variables in the eating disorders

Anorexia nervosa and bulimia nervosa are complex psychosomatic illnesses for which there may be significant biomedical diatheses and sequelae. This paper reviews these biomedical variables, focusing on the medical and nutritional assessment and management of patients with eating disorders and the medical complications that arise in these patients. The paper then examines the relationship between medical illness and eating disorders, including the medical misdiagnoses often given to these patients and the way in which a chronic medical condition such as diabetes mellitus predisposes a patient to an eating disorder. The relationship between eating disorders and pregnancy is also discussed. Through an understanding of these biomedical issues, iatrogenesis can be prevented and treatment can be improved.