Introduction

Chapter 1: Defining Eating Disorders

Chapter 2: Soical Precipitants

Chapter 3: Psychological Precipitants

CHAPTER FIVE COMPLICATIONS

The cachectic condition that results from starvation and the continual abuse inflicted from bingeing and purging, have dramatic, sometimes lethal effects on the body.  The reported mortality rate for anorexia is 5% to 15% (Bruch, 1973).  Though bulimia is not normally lethal, the damage done to the body may result in chronic health problems, even after cessation of the binge-purge behavior.  The medical complications of eating disorders are outlined below:

Anorexia Nervosa

Signs and symptoms
Herzog provides a good description of the anorexic woman.  He states that “cachexia and breast atrophy are observable and the patient may look younger than her biological age.  Her skin is often dry and may be yellow-tinged as a result of carotenemia.  Cyanosis of the extremities is common, especially on exposure to cold temperature, as is lanugo, an increase in the fine hair on the body.  The most common cardiovascular finding among anorexics is bradycardia; heartbeats as low as 25 beats per minute have been reported.  However, there is no clear evidence that such a change predisposes a patient to malignant arrhythmias.  Hypotension has been measured in up to 85% of hospitalized anorexic patients.  Despite malnourishment, an anorexic woman is usually hyperactive and full of energy; lethargy is a worrisome finding because it is not usually present until the end stage of the illness and may reflect cardiovascular compromise (Herzog, 1992)”.

Medical Complications of Anorexia Nervosa
Electrocardiographic Abnormalities – This is very common among low-weight individuals.  These abnormalities include bradycardia, T wave inversions and ST segment depression.  Of most concern are arrhythmias, including supra-ventricular premature beats, ventricular tachycardia with or without exercise and ventricular tachycardia following emetine (ipecac) use.  It is rare to see a patient with Q-T intervals, but when present they can be life-threatening and may cause sudden death.  All of these electrocardiographic abnormalities should revert to normal after weight gain.  Hypotension and dizziness are also common.  Clinicians must be aware of orthostatic hypotension, particularly in prescribing medication such as antidepressants.

Hematologic Changes – These would include pancytopenia, decreased neutrophils and anemia.  Re-feeding will usually reverse these and sometimes iron supplements are necessary.  The need for transfusion is rare.

Gastrointestinal Complications – Constipation and abdominal bloating are common.  This is probably the result of delayed gastric emptying and slowed intestinal motility.  Serum amylase levels and liver enzymes may be elevated.  These abnormalities reverse with weight gain.

Renal Abnormalities – Increased blood urea nitrogen occurs as a result of dehydration.  A decrease in renal concentrating capacity and abnormalities in vasopressin secretion can cause partial diabetes insipidus, resulting in polyuria.  Dehydration also results in the formation of renal calculi.  Hydration and weight gain will reverse all of these changes, although it may take longer for vasopressin secretion to return to normal.

Endocrine Abnormalities – Amenorrhea is characteristic of anorexia nervosa and sometimes occurs even before severe weight loss.  Menses usually returns some time after weight gain.  However, there are also many chronically underweight women who do not lose their menses.  Testosterone levels decrease in males, which impairs reproductive capacity.  Liver function becomes impaired, probably due to fatty degeneration from malnutrition (Bryant-Waugh and Lask).

Thyroid Abnormalities – Anorexics do not have primary hypothyroidism, however they may exhibit some of the clinical features of mile hypothyroidism.  These include constipation, cold intolerance, bradycardia, dry skin and increased relaxation time of deep tendon reflexes.  Thyroxine and thyrotropin levels are usually in the low-normal to normal range.  The clinical signs mentioned are most likely due to a deficiency of triiodothyronine.  These signs abate upon return to normal weight.  Anorexics also demonstrate a lower basal metabolism.  As explained earlier in this study, the body compensates for the reduced supply of calories by conserving its use of the body’s energy.

Skeletal Abnormalities – Anorexic women are predisposed to osteoporosis.  Bone density is decreased, which often leads to fractures of the vertebrae, sternum and long bones.  This is related to the change in hormones which leads to amenorrhea and is normally seen in post-menopausal women.  Return to normal weight does not insure an increase of bone density, and it is uncertain as to whether density levels normalize over a longer period of time.  Bone growth may be permanently impeded in children and adolescents who restrict their food intake.

Cholesterol and Carotene – Interestingly, cholesterol levels are often elevated in anorexics, which is due to disturbed lipoprotein metabolism.  Carotene levels are also elevated in many anorexics.  Both reverse with weight gain.

Psychological and Sensorium Abnormalities – Biochemical changes may occur, which influence thinking, feeling and behavior.  This includes disillusionment regarding actual body size.  Anorexics become out of touch with bodily sensations, such as the inability to discern hunger from satiety.  They also may experience heightened senses, with complaints of music being too loud, a feeling of being out of the body or psychic experience.  The Minnesota study by Keys et al showed an increased incidence of depression, hysteria and hypochondriasis as a result of semi-starvation (Garner et al).  Social isolation and decreased sexual interest were also apparent (Garner et al).

Cognitive Changes – The Minnesota study revealed impaired concentration, alertness, comprehension and judgment during the semi-starvation period (Garner et al).

Bulimia

Signs and symptoms
Bulimia can be difficult to detect because most bulimic individuals (those who only engage in binge-purge behavior and do not have prolonged periods of anorexic behavior) are of normal weight.  There are few obvious signs which would lead one to suspect the presence of bulimia, as in anorexia.  Certain complaints by a patient might lead a physician to further explore the existence of bingeing and purging.  These are swelling of the hands and feet due to dehydration and rebound water retention, abdominal fullness, fatigue, headaches, swelling of the cheeks, dental problems, chest pain, constipation, rectal bleeding or fluid retention.  These are fairly common and vague complaints.  However, there are three characteristic symptoms of bulimia that are easily detected:

1. Russell’s sign – skin changes over the dorsum of the hand, due to using the hand to stimulate the gag reflex.
2. Hypertrophy of the salivary glands, particularly the parotid glands.  This is usually bilateral, painless and quite apparent.
3. Perimolysis, or dental enamel erosion, from the acidity of emesis.

Medical Complications

Fluid and Electrolyte Imbalance – Chronic self-induced vomiting causes hypokalemia (potassium deficit), hyponatremia (sodium deficit) and hypochloremic (chloride) alkalosis.  Hypokalemia leads to muscle fatigue, weakness, numbness, arrhythmias, kidney damage and paralysis.  Laxative abuse, though not an effective mechanism for true weight loss, also causes dehydration and electrolyte depletion, particularly of potassium bicarbonate, which leads to metabolic acidosis.  Electrolyte imbalances may result in cardiac arrhythmias and sudden death (Garner et al).

Tissue Damage – Tissue damage from chronic vomiting is suggested by complaints of sore throat, abdominal pain, esophagitis and mild hematemesis.  Esophageal tearing and bleeding are noted.

Cardiac Abnormalities – Emetine poising, from the use of ipecac to induce vomiting, can cause irreversible myocardial damage.  Arrhythmias and the possibility of sudden death due to electrolyte disturbances.

Gastrointestinal Complications – Elevated serum amylase levels are common and reverse with cessation of vomiting.  Reverse peristalsis can occur, where the stomach regurgitates spontaneously.   Chronic laxative abuse impedes normal absorption and elimination by the digestive system, which leads to chronic constipation and loss of intestinal muscle tone.  Hiatal hernias may occur.

Renal Abnormalities – As a result of dehydration, an increase in blood urea nitrogen occurs, as well as the propensity towards the development of renal calculi.  These changes reverse with hydration.

Endocrine Abnormalities – Although amenorrhea is more common among anorexic women, one clinical study of normal weight bulimic women indicated that more than one-fourth of these patients had irregular menses or amenorrhea (Herzog, 1992).  Infected or swollen salivary glands give the face a chipmunk-like appearance.

Dental Problems – Erosion of enamel occurs due to the hydrochloric acid content of vomitus.  Also, gum disease, cavities and tooth loss are common.

Neurological Abnormalities – Abnormal electrical discharges in the brain have been found in some bulimic patients and is usually associated with electrolyte abnormalities.  Epileptic seizures, muscle spasms (tetany) and tingling in the extremities (peripheral paraesthesia) have been reported (Garner et al).

Depression – This is the most frequent and debilitating consequence of bingeing, witnessed much more frequently in bulimic patients than anorexic patients.   Bulimics continually feel like failures, thus the endless and frustrating cycle of binge-purge behavior.  Depression is also a result of electrolyte imbalances.  This can often be severe enough to lead to suicidal ideation.

Next: CHAPTER SIX MAKING THE DIAGNOSIS