Helping teenagers with eating disorders

Nursing, Oct 2004 by Harris, Marta, Eberly, Marian, Cumella, Edward J

JUST OPEN THE LATEST ISSUE of a teen or women's magazine and you're likely to get this message: Keep losing weight because you can't be thin enough. Like never before, many adolescents, especially girls, are reacting to this message by developing life-threatening eating disorders such as anorexia nervosa and bulimia nervosa. (Binge-eating disorder, a similar problem, is beyond the scope of this article.)

Among adolescent girls, 1% to 3% have bulimia and 1% have anorexia. Only 5% to 15% of all people with anorexia or bulimia are male.

Six percent of people with anorexia and 1% of people with bulimia will die of their diseases. Causes of death associated with these disorders are electrolyte imbalances, cardiac arrest, and suicide.

Because distorted self-image, shame, and denial are characteristics of these disorders, patients rarely seek help on their own. You may be the first health care professional to recognize the problem and intervene. Here, we'll discuss what to look for and how to respond.

How anorexia and bulimia compare

Anorexia is characterized by self-starvation and excessive weight loss. In contrast, the hallmark of bulimia is a secretive cycle of binge eating followed by purging through self-induced vomiting or laxative abuse. Someone with either disorder may exercise obsessively to burn off "excessive" calories and fat.

Considered treatable medical illnesses, anorexia and bulimia have various possible causes, including genetic factors. People prone to perfectionism and those with low self-esteem may use food to gain a sense of control over their lives. Eating disorders often accompany other psychiatric conditions, such as anxiety, depression, and substance abuse.

Distorted body image

Someone with anorexia has a severely distorted body image. Although unnaturally thin, she sees herself as fat and is intensely afraid of gaining weight. Signs and symptoms include:

* inability to tolerate cold

* irregular or absent menstrual periods (if she's prepubescent, onset of menses may be delayed)

* malnutrition and dehydration, leading to hair loss or lanugo, dry skin, and brittle nails

* slow heart rate; possible arrhythmias secondary to electrolyte imbalances

* abnormal lab test results, including low white blood cell count, hemoglobin, and phosphate levels; dyslipidemia; low fasting blood glucose levels; and abnormal liver function studies.

In contrast, someone with bulimia may maintain her weight in the normal range, despite habitual purging, so she may appear normal at first glance. But look at her hands: You may see characteristic tooth marks or excoriations on the knuckles from inducing vomiting. She may also have enlarged parotid glands and dental caries from repeated contact with vomited stomach acid.

Other signs and symptoms of bulimia include:

* electrolyte imbalances

* arrhythmias

* increased amylase levels and complaints of heartburn, vomiting blood, or constipation secondary to dehydration.

Like an adolescent with anorexia, a patient with bulimia may fear gaining weight and have a poor self-image. She may feel deeply ashamed when she binges and relieved when she purges.

How to help

The prognosis for these disorders is unpredictable: Some patients recover after just one episode of an eating disorder; others have recurring episodes for years. Successful treatment requires the collaboration of various health care professionals, including physicians, nurses, nutritionists, and mental health professionals. The goals are to reverse malnutrition, eliminate self-destructive behaviors, correct distorted body image, bolster self-esteem, and maintain remission and recovery.

At the time of diagnosis, the health care provider must determine if the patient's life is in immediate danger. If so, he'll hospitalize her for nutritional support.

Psychotherapy and behavioral therapy are cornerstones of treatment. The patient may not recognize that she's ill and may not wish to stay in treatment. Involving supportive relatives or trusted friends in her long-term therapy may help motivate her to desire recovery and develop new coping skills and behaviors.

Medications prescribed to help manage symptoms associated with an eating disorder include:

* stool softeners to treat constipation.

* hormonal contraceptives to boost estrogen and progesterone levels.

* selective serotonin reuptake inhibitors (SSRIs) and possibly small doses of an atypical antipsychotic such as olanzapine (Zyprexa), in conjunction with counseling, to treat depression and anxiety. Closely monitor any teenager taking antidepressant medication-especially an SSRI, which may increase the risk of suicidal behavior.

The next time you hear a teenager say she's not thin enough, take a closer look. By initiating treatment, you could save her life.

SELECTED WEB SITES

National Institute of Mental Health

http://www.nimh.nih.gov/publicat/eatingdisorders. cfm

National Eating Disorders Association

http://www.nationaleatingdisorders.org

Last accessed on September 1, 2004.

BY MARTA HARRIS, RN; MARIAN EBERLY, RN, DAPA, LCSW, MSW; AND EDWARD J. CUMELLA, PHD