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The Evaluation of Eating and Weight Symptoms in the General Hospital Consultation Setting
The Evaluation of Eating and Weight Symptoms in the General Hospital Consultation Setting CAROLINE P. CARNEY, M.D. WILLIAM R. YATES, M.D.
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 patient 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 (n⳱21), anorexia nervosa (n⳱19), and no psychiatric diagnosis (n⳱18) were the most frequent diagnoses. Record review suggested significant challenges to accurate eating disorder diagnoses in patients presenting with primary medical complaints. (Psychosomatics 1998; 39:61–67)
E
ating disorders in patients presenting for evaluation of medical or surgical illnesses have seldom been studied. The medical morbidity caused by the effects of starvation and purging is significant. In a study by Hall et al., 40% of the bulimic patients had significant medical complications, and 10% of the anorexic patients required intensive care unit hospitalization.1 The effects of eating disorders on pregnancy include impaired fertility, poor maternal nutrition, and low birth-weight infants.2 The association between eating disorders and type I diabetes mellitus (DM) appears longstanding and is widely assumed to complicate treatment of DM.3–5 Little data, however, exists on the diagnosis of eating disorders in patients presenting with primary physical complaints. The purpose of this study is to examine the presentation, evaluation, and diagnosis of eating disorders in a psychiatric consultation setting. VOLUME 39 • NUMBER 1
• JANUARY–FEBRUARY 1998
METHODS Between 1982 and 1990, 65 inpatients and outpatients in a general hospital setting were referred to the psychiatric consultation team for evaluation of an eating disorder. Only female subjects were included in the review. A retrospective chart review, including information on past medical and psychiatric history, physical examination, laboratory data, history obtained by the psychiatric consultant, and psychiatric Received April 4, 1996; revised October 23, 1996; accepted January 24, 1997. From the Department of Internal Medicine and Psychiatry, and the Department of Psychiatry, The University of Iowa College of Medicine, Iowa City. Address reprint requests to Dr. Carney, Department of Internal Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242–1081. Copyright 䉷 1998 The Academy of Psychosomatic Medicine.
61
Evaluation of Eating and Weight Symptoms
and medical diagnoses, was conducted. Retrospective diagnoses based on chart review and follow-up information not available to the original psychiatric consultant were made. All diagnoses were made by using criteria from the DSM-III-R.6 RESULTS All probands were white females. The mean age was 27 years, mode 20 years, and age range 17– 81 years. TABLE 1.
Referring entity by specialty
Specialty
Number
General internal medicine Endocrinology Obstetrics General surgery Neurology Gastroenterology Gynecology Neurosurgery Orthopedic surgery
20 15 7 4 4 3 2 2 2
Note: Other services with one consultation request: cardiology, oncology, psychology, rheumatology, urology, and self-referral.
FIGURE 1.
Sixty-three percent of the study population were referred from general internal medicine or internal medicine subspecialty services. Obstetrics-gynecology patients accounted for 13.9%, surgical patients for 10.8%, and other services for 12.3% of the study population. Forty-six patients were on inpatient status; the remaining 19 patients were seen on outpatient consultation (Table 1)(Figure 1). The most common medical diagnosis at presentation was type I DM (23%). Nine percent of the patients were pregnant (n⳱6). Nearly 8% had abdominal pain/distress. Nine percent had no medical diagnosis for their physical complaints (Table 2). Physicians requesting consultations most frequently described self-induced vomiting (39.1%) as the reason for the consult. Other behaviors included weight loss (31.3%). Twenty percent had vomiting of unknown etiology (presumed non–self-induced), and 20% had bizarre eating habits. A distorted body image was recognized in 15.6% of the probands. Diagnoses made by the consultation service included anorexia nervosa (AN), bulimia nervosa (BN), both AN and BN, eating disorder not other specified (NOS), other psychiatric disor-
Consultation referral source.
Internal Medicine 63% Obstetrics-Gynecology 14% Surgery 11% Other 12%
62
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Carney and Yates
der, or no psychiatric disorder. A given patient may have been diagnosed with more than one diagnosis. From the 65 consultation requests, 19 patients were diagnosed with AN, 21 with BN, 10 with an eating disorder NOS, and 20 with “other” psychiatric disorder, including major depressive disorder and personality disorders. Eighteen patients were given no psychiatric diagnosis. Of the 19 patients diagnosed with AN, in only 2 patients was it evident from the consultation record and chart that the full DSM-III-R diagnostic criteria were met. The most commonly endorsed criteria in those given the diagnosis of AN was Criterion C, a “disturbance in the way in which one’s body weight, size, or shape is experienced” (n⳱12, P⳱0.001). Criterion B “intense fear of gaining weight or becoming fat, even though underweight” and Criterion D “absence of at least 3 consecutive menstrual cycles. . .” were both endorsed in 6 patients only (P⳱0.0017). Only 4
TABLE 2.
Medical diagnoses/concurrent medical problems
Diagnosis
Number
Diabetes mellitus type 1 No medical illness Pregnancy Abdominal pain, unknown etiology Trauma Vomiting, unknown etiology Cardiovascular Overdose Amenorrhea Asthma Grave’s disease Laxative abuse Obesity Sepsis Suicide, other Syncope
15 6 6 5 4 4 3 3 2 2 2 2 2 2 2 2
Note: Other diagnoses occurring one proband only: arthritis, cholecystectomy, cholelithiasis, constipation, demyelinating disease, diabetes mellitus type II, enterovesical fistula, hypertension, myoclonus, pancreatitis, peptic ulcer disease, postpartum state, premenstrual syndrome, rectal ulceration, seizure, sexual assault, somnambulism, upper respiratory infection, viremia.
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• JANUARY–FEBRUARY 1998
patients endorsed Criterion A “refusal to maintain body weight over a minimal normal weight for age and height. . .” (P⳱0.0071). Although 21 probands were diagnosed with BN, only 2 met full diagnostic criteria, evidenced by consultation record review. Nineteen patients diagnosed by the consultation team endorsed Criterion C, “person regularly engages in either self-induced vomiting, . . .” (P⳱0.0005). Seventeen endorsed Criterion A, “recurrent episodes of binge eating . . .” (P⳱0.0001), and 13 endorsed Criterion D, “a minimum average of 2 binge-eating episodes . . .” and Criterion E, “persistent overconcern with body shape and weight” (P⳱0.0001 and P⳱0.0092, respectively). Of the 10 patients diagnosed with an eating disorder NOS, 1 endorsed AN Criterion A (AN-A), and 2 probands each endorsed AN-B, AN-C, and AN-D. Eight patients with an eating disorder NOS endorsed BN-C, while four endorsed BN-E. The remaining bulimic criteria were endorsed by only one patient each. Comparison of consultation team diagnosis and the diagnosis made by the authors revealed that in eight patients given a no eating-disorder diagnosis, the reviewer diagnosed those patients with an eating disorder NOS. Other discrepancies were noted in the diagnosis of AN, BN, or both AN and BN. DISCUSSION The purpose of this study was to determine the characteristics of patients referred to a psychiatric consultation service for the specific evaluation of the presence of an eating disorder. These patients had been seen in the general hospital setting initially for evaluation of a physical complaint and were identified by the care provider as having eating or weight symptoms suggestive of an eating disorder. Most patients were referred from the general internal medicine inpatient and outpatient services (63%). Among specialty services, endocrinology (n⳱15) and obstetrics-gynecology (n⳱9) were the most frequent. All subjects were white females. The mode age was 20 years. Interestingly, the age 63
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ranged from 17 to 81 years. The mean age of the group was 27 years, somewhat higher than the typical age at onset for AN or BN. Of the 65 patients referred for evaluation of an eating disorder, 19 were diagnosed with AN, 21 with BN, and 10 with an eating disorder NOS. Eighteen were given no diagnosis by the psychiatric consult service. Eight of those patients were diagnosed by the authors with an eating disorder NOS by using information that, in some cases, may not have been available to the original consultant psychiatrist. The frequency of a diagnosis being made by the consultant psychiatrist suggests that the primary caregivers have appropriate suspicions about co-existing eating-disorder pathology. Review of the charts suggests that underlying medical conditions were complicated by the presence of an eating disorder. The recognition and treatment of eating disorders may have an important impact on the course of the underlying illness. Physicians requesting consultation should be cognizant of weight changes or odd eating habits, especially in the face of gastroenterological-related symptoms, electrolyte abnormalities, amenorrhea, renal dysfunction, and depression.7 For instance, 11 of 44 of the study patients in whom electrolytes were evaluated had hypokalemia (KⳭ⬍3.5 meq/L). Greenfeld et al.8 recently suggested that in outpatients with eating disorders, hypokalemia in a patient with an eating disorder is virtually certain evidence that the patient is purging by vomiting and/or laxative abuse. The consultant psychiatrist should consider diagnosing eating and weight symptoms as an eating disorder NOS if full diagnostic criteria are not met. In this review, eight patients given no psychiatric diagnosis actually met criteria for an eating disorder NOS when further information was obtained at a time following psychiatric consultation. The diagnosis of eating disorder NOS may alert the primary care or specialty medical provider that underlying psychiatric or social stressors may be contributing to the presence of eating and weight pathology. In a prospective follow-up study, over 50% of the bulimic patients receiving cognitive-behavioral 64
therapy or focal interpersonal therapy no longer met criteria for an active eating-disorder diagnosis.9 If an eating-disorder diagnosis is made and patients are referred for appropriate psychiatric therapy, one could speculate that medical outcome would improve and overall medical expenditures for diagnosis and treatment of physical problems could be diminished. Further longterm study will need to be undertaken to determine if earlier diagnosis and intervention is effective with medical comorbidity. Physical and psychological symptoms displayed by the patients reviewed in this study may provide information about the presence of an underlying eating disorder complicating another disease process or presenting as an occult primary diagnosis. Common presenting complaints included depressed mood, recent suicidal ideation/attempt, vomiting of “undetermined” etiology, abdominal pain, body weight lower than 90% or greater than 110% expected, complaints of “poor appetite,” and complaints of food “intolerance.” Several patients had current or prior alcohol abuse. Complaints of depressed mood occurred in about 25% of the patients. The most frequent underlying medical diagnosis in this group was type I DM (n⳱15). Biggs et al.10 surveyed a group of 42 women with type I DM, dividing the group into insulin withholders and noninsulin withholders. Those women who withheld insulin to control their weight were more likely to have pathological scores on the Eating Disorder Inventory, 2 have past or current symptoms of AN or BN, and to lie to physicians about degree of compliance with the diabetes regimen. The mean glycosylated hemoglobin levels in the insulin withholder group was significantly higher, suggesting poor glycemic control.10 Long-term complications of poor glycemic control include nephropathy, retinopathy, and peripheral neuropathy. Automonic dysfunction from diabetes may lead to gastric paresis and delayed gastrictransit time, which may lead to gastric distension relieved by vomiting.10–13 These symptoms may mimic eating-disorder behavior, making diagnosis of the underlying medical or psychiatric pathology more difficult. PSYCHOSOMATICS
Carney and Yates
Whether an increased incidence of type I DM is noted in anorexia nervosa is debated. Fairburn et al. reported that there was not an increased incidence and that earlier studies supporting an increased incidence were confounded by lack of direct clinical interviews, tertiary referral bias, and inadequate control groups.14,15 Others, however, have shown that from 7% to 19% of persons with diabetes had AN, BN, or a partial syndrome.16,17 Although the prevalence of persons who have diabetes and concurrent eating disorders is debatable, the early recognition and intervention in a diabetic patient with a spectrum of symptoms suggesting an eating disorder may be extremely important to long-term outcome. For instance, bulimic symptoms in persons with diabetes have been positively related to reports of hospitalizations and episodes of ketoacidosis.18 As stated earlier, we suggest that although a patient may not meet full diagnostic criteria for AN or BN, patients with suggestive symptoms or a partial syndrome should at a minimum be diagnosed as having an eating disorder NOS if no organic etiology is determined to account for eating and weight symptoms. Identification and treatment of eatingdisorder pathology may diminish health care costs and medical morbidity. The psychiatric consultant and diabetic care provider must work together closely in the management of these complex patients. At the time of consultation, six patients were pregnant. The effects of eating disorders on pregnancy include poor maternal nutrition, higher perinatal mortality, and low birth weight infants.19 Infants of mothers in remission had higher 5-minute American Pediatric Gross Assessment Record scores when compared with mothers with active restricting and bulimic forms of AN.2 The women with active symptoms also gained less weight, had lower birth weight babies, and had more difficulty breast feeding. Prior studies evaluating maternal weight at time of conception show that pregravid body mass, weight gain during pregnancy, and body-mass index before conception are valid measures of birth weight.20,21 Others have reported that infants had normal birth weights and VOLUME 39 • NUMBER 1
• JANUARY–FEBRUARY 1998
deliveries. In addition, these authors suggested that pregnancy had a pronounced beneficial impact on anorexic and bulimic symptoms during pregnancy that, however, had minimal lasting effect.22 Women who fail to gain weight during pregnancy and present with intractable vomiting or self-induced purging should also be carefully evaluated for the presence of an eating disorder. The children of women with eating disorders may have an increased risk of failure to thrive19,23 and may have inappropriate diets imposed upon them.24,25 Previous authors have recommended that women with active eatingdisorder symptoms should postpone pregnancy until the eating disorder is in remission.2 Women who are infertile and of low body-mass index may have underlying eating-disorder pathology that should be carefully screened for before artificially induced ovulation is started.26 The diagnosis of an eating disorder in a patient presenting with a primary physical complaint may be difficult. In the population of patients studied, only two patients actually requested evaluation for an eating disorder. The others were seen at the request of the referring physician. Detailed review of the patients’ past medical history, past psychiatric history, history of the present illness, physical and laboratory exam, and information obtained by the referring physicians following psychiatric consultation led to some discrepancies in diagnosing the patient and the application of eating disorder NOS to those 8/18 patients not given a psychiatric diagnosis. The consultation process in the study setting seemed hampered by 1) unwillingness of the patient to participate in a psychiatric interview and the potential “hostile” setting for the consultation, 2) poor or little documentation of the psychiatric consultation, 3) little evidence that DSM-III-R criteria was routinely applied, and 4) limited psychiatric follow-up of patients. Patients unwilling to disclose information about actual eating behaviors or body-image beliefs may give the false impression that no eatingdisorder pathology exists. A 1-visit consultation may also fail to elicit enough information about 65
Evaluation of Eating and Weight Symptoms
the case, especially if no historians other than the patient are interviewed. A consultation-liaison psychiatrist who is familiar with pertinent common historical and laboratory findings may be better able to distinguish eating-disorder patients from those with eating or weight symptoms of other causes. A consultant should consider obtaining the following information when evaluating a medical patient presenting with eating or weight symptoms (Table 3).27
should also obtain a review of systems to include the presence of hair loss, easy bruisibility, cold intolerance, and cessation of or irregular menses. Physical Examination The presence of thinning hair, lanugo, dry skin, acrocyanosis, dental decalcification (especially the posterior occlusive surfaces), enlarged parotid glands, and Russell’s Sign (calluses on the dorsal surface of the hand) should be checked.
History Laboratory Attitude toward food and weight; perceptions of physical appearance; diet history, including usual number of meals daily and amount of intake with each meal; type of exercise(s) and time spent in exercise; personal history of eating disorder or affective disorder; and family history of eating or affective disorder should be assessed. Both eating and affective disorders have been shown to have increased incidence in the first-degree relatives of patients with eating disorders.28–31 Additional history must include the use of purgatives, diuretics, diet pills, and laxatives. Symptoms related to the use of these agents include the presence of sensitive teeth, peridontal disease, sore throat, gastroesophageal reflux, hematemesis, lightheadedness upon standing (secondary to orthostatic hypotension), abdominal pain, irritable bowel syndrome, and cardiac palpitations. The consultation-liaison psychiatrist TABLE 3.
Findings suggestive of an underlying eating disorder Type
Vomiting of medically undetermined etiology Body weight below 90% or greater than 110% expected Presence of type I diabetes mellitus Current or prior major depressive disorder Current or prior suicidal ideation/attempt Complaints of “poor appetite” Complaints of abdominal pain of medically undetermined etiology Current or prior alcohol abuse
66
Tests for hypokalemia, leukopenia, anemia, and more rarely thrombocytopenia and hyponatremia should be done. Metabolic alkalosis is the most common acid/base abnormality and may be appreciated in patients who engage in vomiting. Metabolic acidosis is seen in persons with laxative abuse. A mixed acid-base disturbance may be present in patients who engage in more than one form of purging. The consulting psychiatrist may also request sending stool samples to evaluate for surreptitious laxative use and stool osmolality. CONCLUSION The consultation-liaison psychiatrist is put in the unique role of diagnosing a patient who may not desire psychiatric consultation and offering that same patient treatment for a condition that the patient is unwilling to admit. In this setting, we recommend that the psychiatrist act as educator to the patient and the primary caregiver, providing information about the diagnosis, potential outcomes, necessity for follow-up, further evaluation of eating-disorder symptoms and signs, and treatment methods. A preliminary version of this paper was awarded the “1992 Academy of Psychosomatic Medicine’s Resident Paper of the Year Award.” The original paper was presented at the Academy of Psychosomatic Medicine 39th Annual Meeting, October 1992, San Diego, CA. PSYCHOSOMATICS
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References
1. Hall RCW, Hoffman RS, Beresford TP, et al: Physical illness encountered in patients with eating disorders. Psychosomatics; 1989, 30:174–191 2. Stewart D, Raskin J, Garfinkel PE, et al: Anorexia nervosa, bulimia, and pregnancy. Am J Obstet Gynecol 1987; 157:1194–1198 3. Fairburn CG, Steel JM: Anorexia nervosa in diabetes mellitus. BMJ 1980; 280:1167–1168 4. Hillard JR, Lobo MC, Keeling RP: Bulimia and diabetes: a potentially life-threatening combination. Psychosom Med 1983; 24:292–293 5. Hudson MS, Wentworth SM, Hudson JI: Bulimia and diabetes. N Engl J Med 1983; 309:431–432 6. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised. Washington, DC, American Psychiatric Association, 1987 7. Harris RT: Bulimarexia and related serious eating disorders with medical complications. Ann Intern Med 1983; 99:800–807 8. Greenfeld D, Mickley D, Quinlan DM, et al: Hypokalemia in outpatients with eating disorders. Am J Psychiatry 1995; 152:60–63 9. Fairburn CG, Norman PA, Welch SL, et al: A prospective study of outcome in bulimia nervosa and the long-term efects of three psychological treatments. Arch Gen Psychiatry 1995; 52:304–312 10. Biggs MM, Basco MR, Patterson G, et al: Insulin withholding for weight control in women with diabetes. Diabetes Care 1994; 17:1186–1189 11. Powers PS, Malone JI, Coovert DL, et al: Insulindependent diabetes mellitus and eating disorders: a prevalence study. Compr Psychiatry 1990; 31:205– 210 12. Steel JM, Young RJ, Lloyd GG, et al: Abnormal eating attitudes in young insulin-dependent diabetics. Br J Psychiatry 1989; 155:515–521 13. Hillard JR, Hillard PJA: Bulimia, anorexia nervosa and diabetes: deadly combinations. Psychiatr Clin North Am 1984; 7:367–379 14. Fairburn CG, Peveler RC, Davies B, et al: Eating disorders in young adults with insulin-dependent diabetes mellitus: a controlled study. BMJ 1991; 303:17–20 15. Striegel-Moore RH, Nicholson TJ, Tamborlane WV: Prevalence of eating disorder symptoms in preadolescent and adolescent girls with IDDM. Diabetes Care 1992; 15:1361–1368 16. Rodin GM, Danneman D, Johnson LE, et al: Anorexia nervosa and bulimia in female adolescents with insulin-dependent diabetes mellitus: a systematic study. J Psychiatr Res 1985; 19:381–384
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17. Steel JM, Young RJ, Lloyd GG, et al: Clinically apparent eating disorders in young diabetic women: association with painful neuropathy and other complications. BMJ 1987; 294:859–862 18. Stancin T, Lin DL, Reuter JM: Binge eating and purging in young women with IDDM. Diabetes Care 1989; 12:601–603 19. Brinch M, Isager T, Tolstrup K: Anorexia nervosa and motherhood: reproductional pattern and mothering behaviour of 50 women. Acta Psychiatr Scand 1989; 77:98–104 20. Abrams BF, Laros RK: Prepregnancy weight, weight gain, and birth weight. Am J Obstet Gynecol 1986; 154:503–509 21. Allen LH: Effects of nutritional status on pregnancy and lactation, in Malnutrition: Determinants and Consequences, edited by White PL, Selvey N. New York, Alan R. Liss, 1984, pp. 101–109 22. Lemberg R, Phillips J: The impact of pregnancy on anorexia nervosa and bulima. Int J Eat Disord 1989; 8:285–295 23. van Wezel-Meijler G, Wit JM: The offspring of mothers with anorexia nervosa: a high-risk group for undernutrition and stunting? Eur J Pediatr 1989; 149:130–135 24. Lacey JH, Smith G: Bulimia nervosa: the impact of pregnancy on mother and baby. Br J Psychiatry 1987; 150:777–781 25. Stein A, Fairburn C: Children of mothers with bulimia nervosa. BMJ 1989; 299:777–778 26. van der Spuy AM, Steer PJ, McCusker M, et al: Outcome of pregnancy in underweight women after spontaneous and induced ovulation. BMJ 1988; 296:962– 965 27. Carney CP, Andersen AE: Medical aspects and complications of the eating disorders. Psychiatr Clin North Am 1996; 19:657–679 28. Winokur A, March V, Mendels J: Primary affective disorder in relatives of patients with anorexia nervosa. Am J Psychiatry 1980; 130:695–8 29. Halmi KA, Eckert E, Marchi P, et al: Comorbidity of psychaitric diagnoses I anorexia nervosa. Arch Gen Psychiatry 1991; 48:712–718 30. Theander S: Anorexia nervosa. Acta Psychiatr Scand Suppl 1970; 214:1–94 31. Gershon ES, Hamovit JR, Schreiber JL, et al: Anorexia nervosa and major affective disorders associated in families: a preliminary report, in Childhood Psychopathology and Development, edited by Guze SB, Earls FJ, Barrett JE. New York, Raven Press, 1983
67
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 patient 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 (n⳱21), anorexia nervosa (n⳱19), and no psychiatric diagnosis (n⳱18) were the most frequent diagnoses. Record review suggested significant challenges to accurate eating disorder diagnoses in patients presenting with primary medical complaints. (Psychosomatics 1998; 39:61–67)
E
ating disorders in patients presenting for evaluation of medical or surgical illnesses have seldom been studied. The medical morbidity caused by the effects of starvation and purging is significant. In a study by Hall et al., 40% of the bulimic patients had significant medical complications, and 10% of the anorexic patients required intensive care unit hospitalization.1 The effects of eating disorders on pregnancy include impaired fertility, poor maternal nutrition, and low birth-weight infants.2 The association between eating disorders and type I diabetes mellitus (DM) appears longstanding and is widely assumed to complicate treatment of DM.3–5 Little data, however, exists on the diagnosis of eating disorders in patients presenting with primary physical complaints. The purpose of this study is to examine the presentation, evaluation, and diagnosis of eating disorders in a psychiatric consultation setting. VOLUME 39 • NUMBER 1
• JANUARY–FEBRUARY 1998
METHODS Between 1982 and 1990, 65 inpatients and outpatients in a general hospital setting were referred to the psychiatric consultation team for evaluation of an eating disorder. Only female subjects were included in the review. A retrospective chart review, including information on past medical and psychiatric history, physical examination, laboratory data, history obtained by the psychiatric consultant, and psychiatric Received April 4, 1996; revised October 23, 1996; accepted January 24, 1997. From the Department of Internal Medicine and Psychiatry, and the Department of Psychiatry, The University of Iowa College of Medicine, Iowa City. Address reprint requests to Dr. Carney, Department of Internal Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242–1081. Copyright 䉷 1998 The Academy of Psychosomatic Medicine.
61
Evaluation of Eating and Weight Symptoms
and medical diagnoses, was conducted. Retrospective diagnoses based on chart review and follow-up information not available to the original psychiatric consultant were made. All diagnoses were made by using criteria from the DSM-III-R.6 RESULTS All probands were white females. The mean age was 27 years, mode 20 years, and age range 17– 81 years. TABLE 1.
Referring entity by specialty
Specialty
Number
General internal medicine Endocrinology Obstetrics General surgery Neurology Gastroenterology Gynecology Neurosurgery Orthopedic surgery
20 15 7 4 4 3 2 2 2
Note: Other services with one consultation request: cardiology, oncology, psychology, rheumatology, urology, and self-referral.
FIGURE 1.
Sixty-three percent of the study population were referred from general internal medicine or internal medicine subspecialty services. Obstetrics-gynecology patients accounted for 13.9%, surgical patients for 10.8%, and other services for 12.3% of the study population. Forty-six patients were on inpatient status; the remaining 19 patients were seen on outpatient consultation (Table 1)(Figure 1). The most common medical diagnosis at presentation was type I DM (23%). Nine percent of the patients were pregnant (n⳱6). Nearly 8% had abdominal pain/distress. Nine percent had no medical diagnosis for their physical complaints (Table 2). Physicians requesting consultations most frequently described self-induced vomiting (39.1%) as the reason for the consult. Other behaviors included weight loss (31.3%). Twenty percent had vomiting of unknown etiology (presumed non–self-induced), and 20% had bizarre eating habits. A distorted body image was recognized in 15.6% of the probands. Diagnoses made by the consultation service included anorexia nervosa (AN), bulimia nervosa (BN), both AN and BN, eating disorder not other specified (NOS), other psychiatric disor-
Consultation referral source.
Internal Medicine 63% Obstetrics-Gynecology 14% Surgery 11% Other 12%
62
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Carney and Yates
der, or no psychiatric disorder. A given patient may have been diagnosed with more than one diagnosis. From the 65 consultation requests, 19 patients were diagnosed with AN, 21 with BN, 10 with an eating disorder NOS, and 20 with “other” psychiatric disorder, including major depressive disorder and personality disorders. Eighteen patients were given no psychiatric diagnosis. Of the 19 patients diagnosed with AN, in only 2 patients was it evident from the consultation record and chart that the full DSM-III-R diagnostic criteria were met. The most commonly endorsed criteria in those given the diagnosis of AN was Criterion C, a “disturbance in the way in which one’s body weight, size, or shape is experienced” (n⳱12, P⳱0.001). Criterion B “intense fear of gaining weight or becoming fat, even though underweight” and Criterion D “absence of at least 3 consecutive menstrual cycles. . .” were both endorsed in 6 patients only (P⳱0.0017). Only 4
TABLE 2.
Medical diagnoses/concurrent medical problems
Diagnosis
Number
Diabetes mellitus type 1 No medical illness Pregnancy Abdominal pain, unknown etiology Trauma Vomiting, unknown etiology Cardiovascular Overdose Amenorrhea Asthma Grave’s disease Laxative abuse Obesity Sepsis Suicide, other Syncope
15 6 6 5 4 4 3 3 2 2 2 2 2 2 2 2
Note: Other diagnoses occurring one proband only: arthritis, cholecystectomy, cholelithiasis, constipation, demyelinating disease, diabetes mellitus type II, enterovesical fistula, hypertension, myoclonus, pancreatitis, peptic ulcer disease, postpartum state, premenstrual syndrome, rectal ulceration, seizure, sexual assault, somnambulism, upper respiratory infection, viremia.
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• JANUARY–FEBRUARY 1998
patients endorsed Criterion A “refusal to maintain body weight over a minimal normal weight for age and height. . .” (P⳱0.0071). Although 21 probands were diagnosed with BN, only 2 met full diagnostic criteria, evidenced by consultation record review. Nineteen patients diagnosed by the consultation team endorsed Criterion C, “person regularly engages in either self-induced vomiting, . . .” (P⳱0.0005). Seventeen endorsed Criterion A, “recurrent episodes of binge eating . . .” (P⳱0.0001), and 13 endorsed Criterion D, “a minimum average of 2 binge-eating episodes . . .” and Criterion E, “persistent overconcern with body shape and weight” (P⳱0.0001 and P⳱0.0092, respectively). Of the 10 patients diagnosed with an eating disorder NOS, 1 endorsed AN Criterion A (AN-A), and 2 probands each endorsed AN-B, AN-C, and AN-D. Eight patients with an eating disorder NOS endorsed BN-C, while four endorsed BN-E. The remaining bulimic criteria were endorsed by only one patient each. Comparison of consultation team diagnosis and the diagnosis made by the authors revealed that in eight patients given a no eating-disorder diagnosis, the reviewer diagnosed those patients with an eating disorder NOS. Other discrepancies were noted in the diagnosis of AN, BN, or both AN and BN. DISCUSSION The purpose of this study was to determine the characteristics of patients referred to a psychiatric consultation service for the specific evaluation of the presence of an eating disorder. These patients had been seen in the general hospital setting initially for evaluation of a physical complaint and were identified by the care provider as having eating or weight symptoms suggestive of an eating disorder. Most patients were referred from the general internal medicine inpatient and outpatient services (63%). Among specialty services, endocrinology (n⳱15) and obstetrics-gynecology (n⳱9) were the most frequent. All subjects were white females. The mode age was 20 years. Interestingly, the age 63
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ranged from 17 to 81 years. The mean age of the group was 27 years, somewhat higher than the typical age at onset for AN or BN. Of the 65 patients referred for evaluation of an eating disorder, 19 were diagnosed with AN, 21 with BN, and 10 with an eating disorder NOS. Eighteen were given no diagnosis by the psychiatric consult service. Eight of those patients were diagnosed by the authors with an eating disorder NOS by using information that, in some cases, may not have been available to the original consultant psychiatrist. The frequency of a diagnosis being made by the consultant psychiatrist suggests that the primary caregivers have appropriate suspicions about co-existing eating-disorder pathology. Review of the charts suggests that underlying medical conditions were complicated by the presence of an eating disorder. The recognition and treatment of eating disorders may have an important impact on the course of the underlying illness. Physicians requesting consultation should be cognizant of weight changes or odd eating habits, especially in the face of gastroenterological-related symptoms, electrolyte abnormalities, amenorrhea, renal dysfunction, and depression.7 For instance, 11 of 44 of the study patients in whom electrolytes were evaluated had hypokalemia (KⳭ⬍3.5 meq/L). Greenfeld et al.8 recently suggested that in outpatients with eating disorders, hypokalemia in a patient with an eating disorder is virtually certain evidence that the patient is purging by vomiting and/or laxative abuse. The consultant psychiatrist should consider diagnosing eating and weight symptoms as an eating disorder NOS if full diagnostic criteria are not met. In this review, eight patients given no psychiatric diagnosis actually met criteria for an eating disorder NOS when further information was obtained at a time following psychiatric consultation. The diagnosis of eating disorder NOS may alert the primary care or specialty medical provider that underlying psychiatric or social stressors may be contributing to the presence of eating and weight pathology. In a prospective follow-up study, over 50% of the bulimic patients receiving cognitive-behavioral 64
therapy or focal interpersonal therapy no longer met criteria for an active eating-disorder diagnosis.9 If an eating-disorder diagnosis is made and patients are referred for appropriate psychiatric therapy, one could speculate that medical outcome would improve and overall medical expenditures for diagnosis and treatment of physical problems could be diminished. Further longterm study will need to be undertaken to determine if earlier diagnosis and intervention is effective with medical comorbidity. Physical and psychological symptoms displayed by the patients reviewed in this study may provide information about the presence of an underlying eating disorder complicating another disease process or presenting as an occult primary diagnosis. Common presenting complaints included depressed mood, recent suicidal ideation/attempt, vomiting of “undetermined” etiology, abdominal pain, body weight lower than 90% or greater than 110% expected, complaints of “poor appetite,” and complaints of food “intolerance.” Several patients had current or prior alcohol abuse. Complaints of depressed mood occurred in about 25% of the patients. The most frequent underlying medical diagnosis in this group was type I DM (n⳱15). Biggs et al.10 surveyed a group of 42 women with type I DM, dividing the group into insulin withholders and noninsulin withholders. Those women who withheld insulin to control their weight were more likely to have pathological scores on the Eating Disorder Inventory, 2 have past or current symptoms of AN or BN, and to lie to physicians about degree of compliance with the diabetes regimen. The mean glycosylated hemoglobin levels in the insulin withholder group was significantly higher, suggesting poor glycemic control.10 Long-term complications of poor glycemic control include nephropathy, retinopathy, and peripheral neuropathy. Automonic dysfunction from diabetes may lead to gastric paresis and delayed gastrictransit time, which may lead to gastric distension relieved by vomiting.10–13 These symptoms may mimic eating-disorder behavior, making diagnosis of the underlying medical or psychiatric pathology more difficult. PSYCHOSOMATICS
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Whether an increased incidence of type I DM is noted in anorexia nervosa is debated. Fairburn et al. reported that there was not an increased incidence and that earlier studies supporting an increased incidence were confounded by lack of direct clinical interviews, tertiary referral bias, and inadequate control groups.14,15 Others, however, have shown that from 7% to 19% of persons with diabetes had AN, BN, or a partial syndrome.16,17 Although the prevalence of persons who have diabetes and concurrent eating disorders is debatable, the early recognition and intervention in a diabetic patient with a spectrum of symptoms suggesting an eating disorder may be extremely important to long-term outcome. For instance, bulimic symptoms in persons with diabetes have been positively related to reports of hospitalizations and episodes of ketoacidosis.18 As stated earlier, we suggest that although a patient may not meet full diagnostic criteria for AN or BN, patients with suggestive symptoms or a partial syndrome should at a minimum be diagnosed as having an eating disorder NOS if no organic etiology is determined to account for eating and weight symptoms. Identification and treatment of eatingdisorder pathology may diminish health care costs and medical morbidity. The psychiatric consultant and diabetic care provider must work together closely in the management of these complex patients. At the time of consultation, six patients were pregnant. The effects of eating disorders on pregnancy include poor maternal nutrition, higher perinatal mortality, and low birth weight infants.19 Infants of mothers in remission had higher 5-minute American Pediatric Gross Assessment Record scores when compared with mothers with active restricting and bulimic forms of AN.2 The women with active symptoms also gained less weight, had lower birth weight babies, and had more difficulty breast feeding. Prior studies evaluating maternal weight at time of conception show that pregravid body mass, weight gain during pregnancy, and body-mass index before conception are valid measures of birth weight.20,21 Others have reported that infants had normal birth weights and VOLUME 39 • NUMBER 1
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deliveries. In addition, these authors suggested that pregnancy had a pronounced beneficial impact on anorexic and bulimic symptoms during pregnancy that, however, had minimal lasting effect.22 Women who fail to gain weight during pregnancy and present with intractable vomiting or self-induced purging should also be carefully evaluated for the presence of an eating disorder. The children of women with eating disorders may have an increased risk of failure to thrive19,23 and may have inappropriate diets imposed upon them.24,25 Previous authors have recommended that women with active eatingdisorder symptoms should postpone pregnancy until the eating disorder is in remission.2 Women who are infertile and of low body-mass index may have underlying eating-disorder pathology that should be carefully screened for before artificially induced ovulation is started.26 The diagnosis of an eating disorder in a patient presenting with a primary physical complaint may be difficult. In the population of patients studied, only two patients actually requested evaluation for an eating disorder. The others were seen at the request of the referring physician. Detailed review of the patients’ past medical history, past psychiatric history, history of the present illness, physical and laboratory exam, and information obtained by the referring physicians following psychiatric consultation led to some discrepancies in diagnosing the patient and the application of eating disorder NOS to those 8/18 patients not given a psychiatric diagnosis. The consultation process in the study setting seemed hampered by 1) unwillingness of the patient to participate in a psychiatric interview and the potential “hostile” setting for the consultation, 2) poor or little documentation of the psychiatric consultation, 3) little evidence that DSM-III-R criteria was routinely applied, and 4) limited psychiatric follow-up of patients. Patients unwilling to disclose information about actual eating behaviors or body-image beliefs may give the false impression that no eatingdisorder pathology exists. A 1-visit consultation may also fail to elicit enough information about 65
Evaluation of Eating and Weight Symptoms
the case, especially if no historians other than the patient are interviewed. A consultation-liaison psychiatrist who is familiar with pertinent common historical and laboratory findings may be better able to distinguish eating-disorder patients from those with eating or weight symptoms of other causes. A consultant should consider obtaining the following information when evaluating a medical patient presenting with eating or weight symptoms (Table 3).27
should also obtain a review of systems to include the presence of hair loss, easy bruisibility, cold intolerance, and cessation of or irregular menses. Physical Examination The presence of thinning hair, lanugo, dry skin, acrocyanosis, dental decalcification (especially the posterior occlusive surfaces), enlarged parotid glands, and Russell’s Sign (calluses on the dorsal surface of the hand) should be checked.
History Laboratory Attitude toward food and weight; perceptions of physical appearance; diet history, including usual number of meals daily and amount of intake with each meal; type of exercise(s) and time spent in exercise; personal history of eating disorder or affective disorder; and family history of eating or affective disorder should be assessed. Both eating and affective disorders have been shown to have increased incidence in the first-degree relatives of patients with eating disorders.28–31 Additional history must include the use of purgatives, diuretics, diet pills, and laxatives. Symptoms related to the use of these agents include the presence of sensitive teeth, peridontal disease, sore throat, gastroesophageal reflux, hematemesis, lightheadedness upon standing (secondary to orthostatic hypotension), abdominal pain, irritable bowel syndrome, and cardiac palpitations. The consultation-liaison psychiatrist TABLE 3.
Findings suggestive of an underlying eating disorder Type
Vomiting of medically undetermined etiology Body weight below 90% or greater than 110% expected Presence of type I diabetes mellitus Current or prior major depressive disorder Current or prior suicidal ideation/attempt Complaints of “poor appetite” Complaints of abdominal pain of medically undetermined etiology Current or prior alcohol abuse
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Tests for hypokalemia, leukopenia, anemia, and more rarely thrombocytopenia and hyponatremia should be done. Metabolic alkalosis is the most common acid/base abnormality and may be appreciated in patients who engage in vomiting. Metabolic acidosis is seen in persons with laxative abuse. A mixed acid-base disturbance may be present in patients who engage in more than one form of purging. The consulting psychiatrist may also request sending stool samples to evaluate for surreptitious laxative use and stool osmolality. CONCLUSION The consultation-liaison psychiatrist is put in the unique role of diagnosing a patient who may not desire psychiatric consultation and offering that same patient treatment for a condition that the patient is unwilling to admit. In this setting, we recommend that the psychiatrist act as educator to the patient and the primary caregiver, providing information about the diagnosis, potential outcomes, necessity for follow-up, further evaluation of eating-disorder symptoms and signs, and treatment methods. A preliminary version of this paper was awarded the “1992 Academy of Psychosomatic Medicine’s Resident Paper of the Year Award.” The original paper was presented at the Academy of Psychosomatic Medicine 39th Annual Meeting, October 1992, San Diego, CA. PSYCHOSOMATICS
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References
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