Detection and importance of laxative use in adolescents with anorexia nervosa

Pharmacological treatment of eating disorders, comorbid mental health problems, malnutrition and physical health consequences

The pharmacological treatment of patients with an eating disorder (ED) often includes medications to treat their ED, comorbid mental health problems, malnutrition and the physical health problems resulting from it. The currently approved pharmacological treatment options for EDs are limited to fluoxetine for bulimia nervosa (BN) and - in some countries - lisdexamfetamine for binge eating disorder (BED). Thus, there are no approved pharmacological options for anorexia nervosa (AN), even though study results for olanzapine and dronabinol are promising. Topiramate might be an additional future option for the treatment of BN and BED. Selective serotonin reuptake inhibitors (SSRI), mirtazapine and bupropion could be considered for the treatment of comorbid unipolar depression. However, AN and BN are contraindications for bupropion. For ED patients with a manic episode, we recommend olanzapine in AN and risperidone in BN and BED; whereas for bipolar depression, olanzapine (plus fluoxetine) seems appropriate in AN and lamotrigine in BN and BED. Acute anxiety or suicidality may warrant benzodiazepine treatment with lorazepam. Proton-pump inhibitors, gastroprokinetic drugs, laxatives and hormones can alleviate certain physical health problems caused by EDs. Therapeutic drug monitoring, pharmacogenomic testing, a more restrictive use of "pro re nata" (PRN) medication, an interdisciplinary treatment approach, shared decision making (SDM) and the formulation of common treatment goals by the patients, their family or carers and clinicians could improve treatment success and safety. Novel genetic, immunological, microbiome and brain imaging research as well as new pharmacological developments like the use of psychedelics, stimulants, novel monoaminergic drugs, hormone analogues and drugs which enhance the effects of psychotherapy may extend our therapeutic options in the near future.

Excessive exercise among adolescents with eating disorders: examination of psychological and demographic variables

Background While a large number of patients with eating disorders (EDs) engage in excessive exercise (EE), both for weight control and mood regulation, there has been minimal research evaluating the relationship between EE and demographic and psychological factors, especially in adolescent patients. Purpose The goals of this study were to identify the occurrence of EE compared to other ED behaviors and to develop a regression model examining psychological, behavioral and demographic predictors of EE among adolescents with EDs. Methods Demographic and clinical information was determined for 217 adolescent patients in several levels of care (126 outpatient, 61 day program, 28 inpatient) with diagnoses of anorexia nervosa (AN) (24.9%), bulimia nervosa (BN) (25.8%), and eating disorder not otherwise specified (EDNOS) (49.3%). These patients presented to a large ED program and completed a series of questionnaires on admission to the program. Descriptive statistics, t-tests, chi-square analyses and multiple logistic regression were utilized to describe the population of adolescent patients and develop the model for predicting EE. Results Forty-seven percent of patients indicated they participated in EE in the past 4 weeks, compared to 32% for binge eating, 35% for vomiting and 15% for laxative use; 42% of patients with anorexia nervosa participated in EE, compared to 54% with bulimia nervosa and 49% with EDNOS. The regression model that was developed to predict EE, which included factors of depression, anxiety, dietary restraint, age, body mass index (BMI), diagnosis and level of care, correctly classified EE in 71.5% of cases. Dietary restraint and BMI were the two factors found to be significantly associated with EE. Conclusions Forty-seven percent of adolescent patients presenting for treatment of an ED reported participating in EE. This was larger than the numbers of patients reporting other ED behaviors that are commonly assessed, indicating the need for psychoeducation for multidisciplinary treatment teams, assessment, prevention, and clinical treatment services for this problematic behavior. It is important that those who treat patients with ED assess for and monitor EE behaviors that can complicate the treatment.

Gastrointestinal Manifestations of Eating Disorders

Individuals with eating disorders, including anorexia nervosa and bulimia nervosa, may present with a range of gastrointestinal (GI) manifestations. The oral cavity, salivary glands, GI tract, pancreas, and liver can be impacted by nutritional restrictive and binge/purging behaviors. Complications are often reversible with appropriate nutritional therapy. At times, however, the complications in these disorders may be severe, irreversible and even life threatening. Given the often covert nature of eating disorders, the practitioner must be attentive to subtle clues that may indicate their presence. Extensive diagnostic evaluations of the GI manifestations of eating disorders should be used only when nutritional rehabilitation does not remedy the problems.

Eating Disorders in the Adolescent Population:

Adolescents become vulnerable to developing eating disorders as they mature. Very little is known about the prevalence, etiology, assessment, treatment, and outcome of eating disorders among adolescents. In general, research on eating disorders continues to be plagued with design flaws. Future studies need to be prospective research based on larger, more diverse samples of adolescents that represent all developmental stages of adolescence. Consistent diagnostic criteria and definitions of treatment interventions and outcomes also need to be employed. In addition, research should address the identification of protective and risk factors that predict who will actually develop an eating disorder.

The HOPE (Helping to Outline Paediatric Eating Disorders) Project: development and debut of a paediatric clinical eating disorder registry

BACKGROUND

The HOPE (Helping to Outline Paediatric Eating Disorders) Project is an ongoing registry study made up of a sequential cross-sectional sample prospectively recruited over 17 years, and is designed to answer empirical questions about paediatric eating disorders. This paper introduces the HOPE Project, describes the registry sample to-date, and discusses future directions and challenges and accomplishments. The project and clinical service were established in a tertiary academic hospital in Western Australia in 1996 with a service development grant. Research processes were inbuilt into the initial protocols and data collection was maintained in the following years. Recognisable progress with the research agenda accelerated only when dedicated research resources were obtained. The registry sample consists of consecutive children and adolescents assessed at the eating disorder program from 1996 onward. Standardised multidisciplinary data collected from family intake interview, parent and child clinical interviews, medical review, parent, child and teacher psychometric assessments, and inpatient admission records populate the HOPE Project database.

RESULTS

The registry database to-date contains 941 assessments, of whom 685 met DSM-IV diagnostic criteria for an eating disorder at admission. The majority of the sample were females (91%) from metropolitan Perth (83%). The cases with eating disorders consist of eating disorders not otherwise specified (68%), anorexia nervosa (25%) and bulimia nervosa (7%). Among those with eating disorders, a history of weight loss since illness onset was almost universal (96%) with fear of weight gain (71%) common, and the median duration of illness was 8 months.

CONCLUSIONS

Over the next five years and more, we expect that the HOPE Project will make a strong scientific contribution to paediatric eating disorders research and will have important real-world applications to clinical practice and policy as the research unfolds.

A comparison of eating, exercise, shape, and weight related symptomatology in males with muscle dysmorphia and anorexia nervosa

In the context of the lack of nosological clarity surrounding muscle dysmorphia, this paper aims to compare the symptomatic profile of muscle dysmorphia and anorexia nervosa in males whilst using measures sensitive to indexing male body image concerns. Twenty-one male muscle dysmorphia patients, 24 male anorexia nervosa patients, and 15 male gym-using controls completed the Eating Disorder Examination-Questionnaire, the Muscle Dysmorphia Disorder Inventory, the Compulsive Exercise Test, and a measure of appearance-enhancing substance use. Men with muscle dysmorphia and anorexia nervosa demonstrated widespread symptomatic similarities spanning the domains of disturbed body image, disordered eating, and exercise behaviour, whilst differences were consistent with the opposing physiques pursued in each condition. Furthermore, correlational analyses revealed significant associations between scores on muscle dysmorphia and eating disorder measures. The present findings provide moderate support for the notion that muscle dysmorphia may be nosologically similar to anorexia nervosa.

Medical complications of bulimia nervosa and their treatments

OBJECTIVE

To present a cogent and practical review of the medical complications and their treatment in patients with bulimia nervosa.

METHOD

Thorough review of the medical literature from 1990 to current in regards to the medical complications of bulimia nervosa and the therapeutic intervention that are effective to treat them.

RESULTS

Extensive and detailed review of the medical complications of bulimia nervosa.

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.

Detection of polyethylene glycol-based laxatives in stool

The ability to test stool for laxatives is an important part of patient care in some clinical circumstances. Some patients take or are given laxatives surreptitiously. Additionally, failure to take prescribed laxatives may result in treatment failure in children with constipation or encopresis. Although laboratory methods have been available to identify many laxatives in the stool, tests are not available for detecting polyethylene glycol (PEG)-based laxatives. PEG-based laxatives are frequently used in the treatment of children with constipation. We developed a mass spectrometry (MS)-based analysis for detecting PEG in stool and verified the technique in an adult volunteer. We then piloted the assay on stools from children taking PEG for constipation versus children with diarrhea who were not taking PEG. Eleven subjects with diarrhea and 8 receiving PEG were enrolled. Nine of the children with diarrhea and 7 receiving PEG were evaluated by MS. All 3 subjects with PEG who had a stool osmolal gap determined had elevated gaps. Stools of all 7 subjects with PEG were positive for PEG by MS, whereas none of the 9 subjects with diarrhea had stool positive for PEG. This new MS methodology to test stool for PEG is described. It is likely to prove useful in the documentation of surreptitious PEG administration and in evaluation of PEG treatment failure.

Features associated with diet pill use in individuals with eating disorders

We investigated the relation between diet pill use and eating disorder subtype, purging and other compensatory behaviors, body mass index (BMI), tobacco and caffeine use, alcohol abuse or dependence, personality characteristics, and Axis I and Axis II disorders in 1,345 participants from the multisite Price Foundation Genetics Studies. Diet pill use was significantly less common in women with restricting type of AN than in women with other eating disorder subtypes. In addition, diet pill use was associated with the use of multiple weight control behaviors, higher BMI, higher novelty seeking, and the presence of anxiety disorders, alcohol abuse or dependence, and borderline personality disorder. Findings suggest that certain clinical and personality variables distinguish individuals with eating disorders who use diet pills from those who do not. In the eating disorder population, vigilant screening for diet pill use should be routine clinical practice.

Pediatric Toxicology

Pediatric patients present unique concerns in the field of medical toxicology. First, there are medicines that are potentially dangerous to small children, even when they are exposed to very small amounts. Clinicians should be wary of these drugs even when young patients present with accidental ingestions of apparently insignificant amounts. Next, over-the-counter laxatives and syrup of ipecac, although not commonly considered abused substances, may be misused in both the setting of Munchausen's syndrome by proxy and in adolescents who have eating disorders. Their use should be considered in any gastrointestinal illness of uncertain origin. Finally, as the use of syrup of ipecac at home now has been discouraged by many, some have explored using activated charcoal at home as a new method of prehospital gastrointestinal decontamination. The literature examining activated charcoal and its use in this capacity is discussed.

Features associated with laxative abuse in individuals with eating disorders

OBJECTIVE

Laxative abuse is common in patients with anorexia and bulimia nervosa and has been associated with longer duration of illness, suicide attempts, impulsivity, and greater eating and general psychopathology. We explored the extent to which laxative abuse was associated with specific psychopathological features across eating disorder subtypes.

METHODS

Participants were 1021 individuals from the multisite, International Price Foundation Genetic Studies. Axis I disorders, personality disorders and traits, and obsessive compulsive features were assessed.

RESULTS

Laxative abuse was associated with worse eating disorder and general psychopathology and higher prevalence of borderline personality disorder (BPD). Symptom level analyses revealed that specific features of BPD, including suicidality and self-harm, feelings of emptiness, and anger, were most strongly associated with laxative abuse.

CONCLUSIONS

The function of laxative abuse may differ across individuals with eating disorders, alternatively serving as a method of purging and a form of self-harm.

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.

Purging behaviors and comorbidity as predictive factors of quality of life in anorexia nervosa

OBJECTIVE

This study examined the predictive factors for the physical and mental summary components (PCS and MCS) of quality of life (SF-36) in patients with anorexia nervosa.

METHOD

Forty-seven patients with anorexia nervosa were studied. Assessment comprised psychiatric diagnosis by a clinical structured interview for Axis I disorders (SCID-I) and personality disorders (SCID-II), Clinical Global Impression (CGI), and Quality of Life (SF-36).

RESULTS

Anorexia nervosa, restrictive type, was diagnosed in 73.9% of the patients and 51% of the patients presented with comorbidity on Axis I or Axis II or both. The predictive variables for the PCS were poor outcome in previous year, comorbidity on Axes I and II, and female gender. The predictive variables for the MCS were the presence of comorbidity in one or the other of the Axis I or II disorders and purging behaviors.

DISCUSSION

The current study suggests the importance of comorbidity and purging behaviors in the quality of life of these patients with anorexia nervosa.

The associations between laxative abuse and other symptoms among adults with anorexia nervosa

OBJECTIVE

The purpose of the current study was to examine the association between laxative abuse and other symptoms and features among adult patients presenting with anorexia nervosa.

METHOD

One hundred and seventeen patients with anorexia nervosa were studied. Laxative abusers and nonabusers were compared.

RESULTS

Compared with nonabusers, laxative-abusing patients had higher ratings on the Ineffectiveness, Body Dissatisfaction, and Drive for Thinness subscales on the Eating Disorders Inventory (EDI), as well as more depressive and somatization symptoms. There was an association between laxative abuse and low self-esteem.

DISCUSSION

Laxative abuse appears to be associated with especially severe psychopathology and low self-esteem among subjects with anorexia nervosa.

A blinded laxative taper for patients with eating disorders

OBJECTIVE

To evaluate a blinded laxative taper, supervised entirely by pharmacists, in eating disorder patients with laxative dependency.

METHODS

All subjects received a blinded laxative taper according to a set protocol, in addition to the usual treatment for their eating disorder. No specific treatment was given for laxative dependency other than the pharmacist's supervisions of the blinded taper.

RESULTS

Ten patients were enrolled, of whom seven completed the study. Five of the seven patients (71%) decreased their laxative intake by at least 50%. Of these seven patients, three withdraw completely from laxative use.

DISCUSSION

A standardized blinded laxative taper shows promise as a treatment option for laxative dependency in patients with eating disorders. The laxative taper may be less costly and more available than inpatient or psychologically based treatment because it can be given on an outpatient basis under the supervision of a pharmacist.

Eating disorders in males

Eating disorders are one of the rare psychiatric disorders with a large preponderance of female patients. The other articles in this issue review eating disorders in children and adolescents and focus primarily on female patients. This article reviews the eating disorders that occur in male children and teenagers, including anorexia nervosa, bulimia nervosa, binge eating disorder, a subtype of body dysmorphic disorder named muscle dysmorphobia, and obesity. This article reviews subgroups of boys who are at higher risk for developing eating disorders. The article commences with the difference in male perceptions of body image and dieting behaviors.

Outcome predictors in anorectic patients after 6 months of multimodal treatment

BACKGROUND

Anorexia nervosa is a severe disorder that often responds poorly to treatment. At this time, little is known about pretreatment predictors of response.

METHODS

A sample of 42 restrictor type anorectics was tested at the assessment phase and after 180 days retested using the Temperament and Character Inventory and Eating Disorder Inventory 2 along with other clinical evaluation instruments. After 180 days of treatment with multimodal 'network' therapy, the patients were divided into two groups. The first group included patients who showed relevant clinical improvement; the second group included patients considered 'not yet responding'. Data collected from the not-yet-responding group were compared by the t test with the other group's data to evaluate prognostic indexes.

RESULTS

Diagnosis of personality disorder, which afflicted about 50% of patients, seemed not to be a relevant prognostic factor. However, a lower novelty seeking was characteristic of the nonresponder group. Higher levels of asceticism and maturity fears also characterized the nonresponder group.

CONCLUSION

Present data suggest some elements that could be useful to focus pharmacotherapy, psychotherapy and family counseling on the current psychopathology of each patient.