Organ systems
Signs and symptoms
Laboratory studies/physical examination
Whole body
Low body weight; dehydration, weakness; lassitude; hypothermia
Check weight every visit; make sure patient has not artificially increased weight by drinking water or putting objects in her clothes
Cardiovascular
Orthostatic hypotension, palpitations, arrhythmias, bradycardia, dizziness, mitral valve prolapse, chest pain, cardiomyopathy in ipecac abusers
ECG; prolonged PR and QTc intervals; ST-T wave abnormalities
Chest X-ray: small heart
Endocrine, metabolic, reproductive
Fatigue; cold intolerance, low body temperature; oligomenorrhea; amenorrhea; decreased libido; infertility; arrested sexual development; increased pregnancy and neonatal complications
Decreased T3, T4, hypokalemia (with hypokalemic hypochloremic alkalosis), hypomagnesemia, hypophosphatemia, increased serum cortisol, increased serum cholesterol, decreased estrogen, prepubertal patterns of LH, FSH
Pelvic ultrasound: lack of follicular development
Musculoskeletal
Weakness, muscle wasting, bone pain, pathological fractures, point tenderness
DEXA scan reveals osteopenia or osteoporosis in hip and lumbar spine
Central nervous system
Depression, cognitive and memory dysfunction, irritability, apathy, seizures (rare), obsessiveness
Cortical atrophy, ventricular enlargement in CT and MRI, abnormal cerebral blood flow in PET scan, abnormal EEG
Vitamin deficiencies, increased serum carotene
Gastrointestinal
Bloating, abdominal pain, Mallory-Weiss tears; constipation, pancreatitis
Occasionally abnormal liver functions, increased serum amylase, abnormal bowel sounds
Hematologic
Bruising/clotting abnormalities
Anemias (normocytic, microcytic, macrocytic), decreased sedimentation rate, thrombocytopenia, decreased B12, decreased folic acid
Case History: Continued
In the second meeting, gynecologist Linda Cerise discusses Sarah Violet’s eating behavior in more detail. Sarah understands that she uses food as a “mood regulator” and that her gastric pain is related to bulimia nervosa, due to excessive induced vomiting resulting in acid erosion of the esophagus. Meanwhile, Linda gets the results from laboratory tests as well as hormone levels and abdominal and renal sonography, all of which are normal. To enhance compliance, Linda explains to Sarah the effects and side effects of oral contraception.
While talking with Sarah, Linda experiences that it is difficult to convince Sarah to see a mental health professional. However, Sarah describes to Linda that she wants first and foremost to gain better control over her emotional outbursts, which lead to severe disputes with her partner. Following that, she acknowledges that she has problems getting out of bed and feels unable to cope with the needs of her child. Mostly, her mother takes care of these tasks.
Linda explains that she is a gynecologist who may be able to suspect a mental health problem but is not able to diagnose or treat such a problem. Sarah understands that and finally agrees to a consultation.
The next appointment takes place after Sarah’s consultation with a psychiatrist and psychotherapist who prescribes sertraline. Because he also considers Sarah to have a personality disorder of a compulsive type, he also prescribes quetiapine (an atypical antipsychotic drug).
The third meeting with Sarah and her mother makes clear that outpatient treatment will not be sufficient. Sarah is not able to structure her daily life nor keep any agreement with members of her family nor take the remedies regularly. This means she will need a more continuous treatment. She agrees to be admitted at a day care department of the social-psychiatric ward. The referral was, of course, done in Sarah’s presence and with her explicit consent.
9.5 Etiology and Pathogenesis
Eating disorders may result from different causes, and often, like in our case description, there seems to be a confluence of comorbidity and psychosocial risk factors. Because no large-scale or long-term epidemiological studies are available, etiology is described in terms of risk factors.
9.5.1 What Are the Symptoms of an Eating Disorder (AN, BN, BED)?
Eating disorders may cause gynecological, fertility, and obstetrical symptoms.
When one wants to understand eating disorders, the most apparent symptoms are a negative body image, body dissatisfaction, and a basic feeling of lacking self-confidence. Next to these three most prominent symptoms, a wide variety of other symptoms may occur, as depicted in Table 9.3. Table 9.3 shows an overview of risk factors and symptoms of the somatic, the mental, and the social level.
Table 9.3
Symptoms and characteristics of eating disorders
Below you will find a list of symptoms and characteristics at the somatic, mental, and social levels, which may also occur in early stages of an eating disorder and may point to this type of psychological disease |
Somatic level |
Amenorrhea |
Weight loss |
Weight gain |
Digestion problems (particularly meteorism—raw fruit and vegetables, increased food intolerances) |
Dysphagia |
Nausea |
Destruction of dental enamel |
Rhagades of the corner of the mouth |
Chemical burns on hands from vomiting |
Hair loss |
Deficiencies revealed by blood tests (cave: hypokalemia, hyponatremia) |
Decreased urine specific gravity—polydipsia |
Cardiovascular problems |
Tachycardia |
Low blood pressure |
Fainting |
Sleep disorders |
Excessive exercising |
Underweight after delivery |
Mental level |
Compulsive thoughts |
Compulsive behavior |
Depression |
Anxiety |
Other comorbidities: drugs, alcohol, pharmaceuticals |
Strong performance orientation |
Strong body awareness |
Low self-confidence despite obvious skills and abilities |
Dependent personality |
High degree of adaptability |
Weight monitoring (extremely accurate and fast provision of weight information) |
Strong preoccupation with food |
Excessively healthy diet |
Social level |
Critical life events |
Traumatic experiences (sexual abuse) |
Life transition crises |
Separation crises |
Crises at school or at the workplace |
Change of residence |
Social withdrawal |
“Picture book family” |
“Façade family” |
Apparently harmonious relationships but with symbiotic ties |
Anorexia nervosa is characterized by being severely underweight, which suppresses the hypothalamic hypopituitary axis. Gynecological, fertility, and obstetrics effects of AN are:
Gynecological effects: menstrual abnormalities, such as amenorrhea, oligomenorrhea, or irregular menses
Fertility effects: infertility due to amenorrhea or oligomenorrhea
Obstetrical effects: increased risk of fetal growth retardation and vitamin deficiencies resulting in reduced birth weight and preterm delivery
Postpartum: increased risk of feeding problems and an increased risk to suffer from postpartum depression
In bulimia nervosa, women are rarely underweight. Therefore, in only half of the women, suppression of the hypothalamic hypopituitary axis is present. Gynecological, fertility, and obstetrics effects of BN are:
Gynecological effects: menstrual abnormalities, such as amenorrhea, oligomenorrhea, or irregular menses
Fertility effects: infertility due to amenorrhea or oligomenorrhea
Obstetrical effects: increased risk of fetal growth retardation and vitamin deficiencies resulting in preterm delivery
In binge eating disorder, women are usually obese. In this group, insulin resistance is more apparent. This leads to increased insulin levels, elevating androgen production. Polycystic ovary syndrome (PCOS) and hyperandrogenism are clinical features of this phenomenon, which frequently occurs in women. Gynecological, fertility, and obstetrics effects of BED are:
Gynecological effects: menstrual abnormalities, such as amenorrhea, oligomenorrhea, or irregular menses. Hyperandrogenism leading to hirsutism, acne, acanthosis nigricans, and, less commonly, clitoromegaly
Fertility effects: infertility due to amenorrhea or oligomenorrhea
Obstetrical effects: increased risk of pre-eclampsia, fetal macrosomia, fetal growth retardation, gestational diabetes, and obstructed labor with an increased risk for instrumental delivery or emergency caesarean section
9.5.2 Which Risk Factors Are Associated with Eating Disorders?
Risk factors of eating disorders are the following:
Patient histories may show family conflicts or so-called façade families, which means that at first glance, everything looks great, but at a closer look, a pathological pattern can be identified (e.g., overprotection of children or even sexual abuse). Frequently, alcohol abuse in one parent and/or neglect during childhood has been present.
Sexual, physical, or mental violence during childhood and adolescence is seen more frequently in women with eating disorders than in women without these disorders [26, 27].
Self-harm behaviors, such as cutting arms or thighs, are more frequently seen, which may be a sign of borderline disorder and/or depersonalization as a consequence of a traumatic experience.
All in all, the pathogenesis may vary depending on different comorbidities. More detailed psychodynamic explanation patterns would go beyond the scope of this chapter.
9.5.3 Which Sociocultural Factors May Play a Role?
A precursor to eating disorders has found to be previous dieting [29]. A current survey conducted in Vienna among 1427 girls and boys, aged 13–15 years, at 33 schools revealed that nearly one-third of the girls (31 % [95 % CI: 27–34 %]) is afraid or very afraid of gaining weight compared to 15 % of the boys [95 % CI: 12–17 %]), and 40 % [95 % CI: 36–43 %] of the girls reported that weight and shape influence their self-esteem considerably. Weight and shape are permanently checked, and eating behavior is dictated by calories, resulting in a destabilization of the hunger and satiety mechanism. Two-thirds of the girls surveyed often or constantly think about their appearance (95 % CI: 65–72 %), 16 % of the girls (95 % CI: 14–19 %) avoid specific foods due to weight and shape concerns, 11 % (95 % CI: 9–13 %) skip meals, 13 % (95 % CI: 11–16 %) use appetite suppressants, and another 13 % (95 % CI: 11–16 %) reported 24-h fasting [30].
There is evidence that there are links between body image dissatisfaction on the one hand and images in Western media and fashion industry of perfectly slim female bodies on the other, which can result in eating disorders [11, 31]. Women with different ethnicities and cultural backgrounds are also vulnerable for eating disorders [14, 28, 32]. Quite recently, eating disorders in middle-aged women have been recognized. This has to be explained by a culture of “young forever” as well as age discrimination. Since women’s identities are more closely connected to their bodies and appearance, it is particularly they who feel the pressure.
Case History: Continued
Shortly after her stay at the day care unit, Sarah Violet comes to the psychosomatic outpatient department. Her hospital discharge letter states that she suffers from an emotionally unstable personality disorder. She received citalopram and quetiapine as well as chlorprothixene to be taken as needed. Sarah looks to be in a better state—optimistic—but has discontinued her stay without follow-up care; Linda had tried to convey to her the importance of follow-up care.
Eighteen months later Sarah comes again to the gynecological outpatient department with shifting symptoms of gastric and pelvic pain and spotting. She is afraid of pregnancy because she forgot to take her oral contraceptive. It seems she has fallen back to her former eating behavior. Examinations are without pathological findings.
Sarah gained a lot of weight and is in a very bad state. She has not taken her medication regularly for several months. The exam turns out to be difficult, spanning the requested decrease of her stay and the unwanted implications such as being addiction prone and gaining weight. Her relationship is at the brink of breaking up. She is constantly quarrelling with her parents. It seems that her wish for another child is ambivalent. Linda discusses Sarah with the psychiatrist, and he decides to refer Sarah to a long-term stay in a psychiatric hospital with a specialization in eating disorders.
9.6 Specific Diagnostic Aspects
9.6.1 What Are the Diagnostic Key Questions?
Zerbe [1] offers the following key questions for initiating a talk with patients when an eating disorder is suspected:
Has there been any change in your weight in the past 6–12 months?
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