Fluid restriction in anorexia nervosa: a neglected symptom or new phenomenon?

OBJECTIVE

The deliberate restriction of fluids to control weight is even more dangerous than food restriction since it results in several serious medical complications. However, there has been scant attention given to the anorexia nervosa patient's manipulation of fluids. It is our clinical impression that fluid restriction in this illness is more common than previously thought.

METHOD

We summarize the demographic and clinical features of six cases of anorexia nervosa and one case of eating disorder not otherwise specified (ED-NOS) (subthreshold anorexia nervosa), where fluid restriction was a major behavioral problem. We then describe two of the anorexia nervosa cases in more detail. All were treated at a dieting disorders unit affiliated with the University of Sydney. Their preadmission history, psychological and physical status on admission, results of physical investigations, the beginning of the fluid restriction, fluid and food intake throughout treatment, and the resolution of the fluid restriction were assessed.

RESULTS

Patterns emerged in the relationship between eating and drinking. In all cases, food restriction was severe prior to the onset of fluid restriction but, notably, fluid intake recommenced prior to food intake. The reasons given by patients for restricting fluid were that it contained calories and that it made them feel full. Most anorexic patients equate feeling full with "feeling fat." Furthermore, they feel fully in control when they restrict fluid as well as food and this produces a strong motivation to maintain the behavior.

DISCUSSION

The cases illustrate the insidious nature and serious consequences of fluid restriction and the difficulties managing dieting-disordered patients who undertake it. Careful attention must be given to assessment and clinicians should be aware of fluid restriction as an important aspect of anorexic behavior.

Intensive nutritional counselling in bulimia nervosa: a role for supplementation with fluoxetine?

OBJECTIVE

The aims of the paper are to determine whether nutritional counselling is associated with an improvement in bulimic symptomatology, whether this improvement is maintained during post-treatment follow-up, and whether the addition of fluoxetine 3 x 20 mg/day confers additional benefit.

METHOD

Psychological, pharmacological and combined psychopharmacological treatments of bulimia nervosa were reviewed briefly. Sixty-seven patients referred to specialist eating disorder services who fulfilled strict diagnostic criteria were treated with intensive nutritional counselling and randomly assigned to either fluoxetine 3 x 20 mg/day or placebo. After a 1-week 'wash-out', active treatment was given over 8 weeks, followed by post-treatment interviews at 12 and 20 weeks.

RESULTS

Both groups of patients improved significantly during treatment. In some respects, the fluoxetine group did slightly better as demonstrated by the items 'restraint', 'weight concern' and 'shape concern' (p < 0.05 vs p < 0.0001) on the Eating Disorder Examination (EDE). Fluoxetine patients decreased their energy intake and lost a modest amount of weight. They went on to regain weight during the follow-up period, returning to levels higher than they were initially. These patients also appeared more likely to have a recurrence of symptoms, as shown by the fall in percentage of binge-free patients and by changes in the EDE.

CONCLUSION

Nutritional counselling is an effective means of treating bulimia nervosa, with improvement maintained up to 3 months follow-up. The addition of fluoxetine may confer some benefit during active treatment, but its discontinuation may contribute to a higher rate of recurrence of symptoms post treatment. Of course, this study cannot be extrapolated to the efficacy of fluoxetine when used as the only form of treatment in patients for whom intensive nutritional counselling or other structured psychological programs are not available.