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When symptoms reflect deeper problems: Spotting eating disorders in the ED

Monday August 13, 2012
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Eating disorders can take months, even years, to treat effectively. But ED nurses who can identify patients with such a disorder can help get them on the right track to healing. A big challenge, however, is that patients with eating disorders often go to great lengths to conceal the problem.

Recognizing eating disorders in the ED, helping patients understand they are ill and steering them to ongoing mental and physical care requires preparation far in advance of the patient encounter, experts say. “For most eating disorders, recovery is a very long-term process,” said Bobbi O’Brien, RN, PhD, clinical psychologist at Eating Disorders Associates in Torrance, Calif. “You can get through the acute part, the medical part, pretty quick. But the rest — psychiatric issues, body image, self-esteem, co-occurring depression or anxiety disorders, family dynamics — that can take 10 years or more.”

A complex issue

Psychiatry’s diagnostic manual, the DSM-IV-TR, recognizes three main categories of eating disorders: anorexia nervosa, bulimia nervosa and eating disorders-not otherwise specified. Patients with anorexia have an obsessive fear of gaining weight, and so dangerously limit food intake. They might alternately “purge” nutrients by using laxatives or diuretics, or by inducing vomiting. Patients with bulimia, meanwhile, will eat in binges, followed by behaviors such as purging or fasting to compensate for the overeating. (In binge eating disorder, mentioned briefly in the DSM, no such compensatory behavior occurs.)

Less commonly, patients might suffer from other aberrations in eating behavior, said Jeff Solheim, RN-BC, MSN, CEN, CFRN, FAEN, a national consultant, nursing educator and former ED nurse. These include diabulemia, in which type 1 diabetics manipulate their insulin levels for weight loss; pica, in which patients eat nonfood substances such as dirt, hair, feces or plastic; and orthorexia, when patients obsessively pursue a pure, healthy diet. Patients also might suffer from nocturnal eating disorders, in which they are compelled to eat at night.

A recent study at the University of Michigan Medical Center in Ann Arbor, involving ED patients ages 14 through 20, found that 16% screened positive for some type of eating disorder. That figure compares with prevalence estimates in the general population of up to 1% for anorexia, 3% for bulimia and 5% for other eating disorders, the researchers noted. Those who screened positive in the study for a disorder were three times as likely to be female, obese and/or depressed, researchers reported online in May in the International Journal of Eating Disorders.

The stereotype about who suffers from the most common eating disorders — typically an adolescent or young adult female — might cloud a nurse’s assessment, O’Brien noted. Her patients have ranged from 12-year-olds to people in their 50s who still struggle with their condition. Meanwhile, males who are trying to stay at a specific weight as horse jockeys, or for sports like wrestling or boxing, might be misusing diuretics or exhibiting other purging behavior, Solheim said.

An estimated half of eating disorders may go undetected in clinical settings, a statistic that gnaws at Solheim. “It just breaks my heart,” he said. “Here are people who desperately need help and we miss it.”

Signs and symptoms

Part of the problem is that patients with eating disorders most often present with vague physical complaints such as fatigue, dizziness, dehydration, palpitations or seizures. They may have fainted or may be having chest pain. They could have edema in the limbs or face or might complain of thinning hair, feeling cold, having little appetite or frequently throwing up.

For nurses who suspect an eating disorder, asking the patient is the first step, said Maria C. La Via, MD, medical and clinical director for the University of North Carolina at Chapel Hill Eating Disorders Program. Height and weight and orthostatic blood pressure and pulse can be key indicators. And depending on the suspected eating disorder, “labs can be as helpful as vital signs,” La Via said. For patients who purge, an electrolyte panel might show potassium or chloride deficiencies or elevated carbon dioxide levels. Bradycardia could indicate electrical problems in the heart, as would ECG findings of low voltage or prolonged QT interval — all tipoffs of a possible eating disorder.

In anorexia, cardiac insufficiency is a major concern, Solheim said, as over time the heart loses contractility and mass, putting patients at eventual risk of heart failure.

Other clues include loss of bone density (perhaps evident from a stress fracture or other unlikely fracture); sunken eyes (due to dehydration); esophagitis (from repeated vomiting); lanugo (a layer of fine, fuzzy hair on the body); and in females, lack of menstrual periods. A scabbed or calloused knuckle — a result of forced vomiting — also might indicate anorexia or bulimia.

Overall, bulimia and binge eating disorder can be harder to detect — in part because patients who binge might be of normal weight or overweight. O’Brien said that compared with other patients with weight problems, binge eating involves a psychological element like feeling pressured, “driven,” out of control, ashamed or guilty.

Nurses who suspect binge eating disorder can ask about patients’ eating patterns in a typical day and whether they overeat compared with other people, she said. Structured interviewing tools like the Eating Attitudes Test or the Eating Disorder Inventory also can be helpful.

Solheim urges ED nurses to overcome any discomfort they have in confronting a potential eating disorder. “You should ask very pointed questions, such as ‘What’s your ideal weight? How do you get there? Have you had episodes involving eating that you can’t control?’”

Providing care

When an eating disorder is identified, Solheim advises ED nurses to focus initially on two aspects of care. One is the safety of the patient, who might be prone to further self-harm. (Self-mutilating behaviors such as cutting sometimes accompany eating disorders.) The other, of course, is treating urgent physical symptoms.

It’s vital, especially in patients with severe illness, to enlist the aid of specially trained professionals to minimize risks such as refeeding syndrome, a potentially dangerous metabolic complication that can result from nutritional support. Caloric intake must be increased gradually, with close monitoring of vital signs, fluid shifts, weight and electrolytes. Also, administering IV fluids at a typical rate might in some patients precipitate heart failure, experts note.

La Via suggests ED nurses be upfront with patients and their loved ones if an eating disorder is suspected, discussing medical findings and the possible long-term impact on health. A hospital’s psychiatric resources also should be tapped to assist with assessment and referral.

O’Brien, whose clinic oversees the Medical Stabilization Program for Patients with Eating Disorders at Torrance Memorial Medical Center, urges EDs to foster relationships with specialists who can evaluate and place patients for ongoing care and to develop a list of various types of eating disorder treatment resources available locally.

Such programs include:
• Minimally restrictive outpatient therapy without meal monitoring
• Intensive outpatient therapy requiring four or five hours of participation a day and possibly some meal monitoring
• Partial hospitalization from morning till evening, with meal monitoring and therapy
residential treatment, with round-the-clock supervision as well as therapy

While EDs are not the optimal place to treat an eating disorder, they are very often the first, O’Brien notes. “For a lot of people, that is their way of crying out for help — to go to the ED with some kind of symptom,” she said. “They hope they [ED personnel] will do something about it, because their parents or their husband isn’t doing anything about it.”


Karen Patterson is a freelance writer. Post a comment below or email specialty@nurse.com.
Eating disorders — A snapshot

An estimated 8 million to 10 million Americans have eating disorders.

• Rates of minorities with eating disorders are similar to those of Caucasians.

• Lifetime prevalence for anorexia nervosa is 0.6%; average age of onset is 19.

• Lifetime prevalence for bulimia nervosa is 0.6%; average age of onset is 20.

• Lifetime prevalence for binge eating disorder is 2.8%; average age of onset is 25.

• Anorexia is the third most common chronic illness among adolescents.

• Only one-third of people with anorexia in the community, and 6% of people with bulimia, receive mental healthcare.

• Among people with anorexia, 20% will die prematurely from complications related to their condition.

• Girls who diet frequently are 12 times as likely to binge-eat as girls who don’t diet.

• The average cost for a month of inpatient treatment for an eating disorder is about $30,000.

Sources: National Institute of Mental Health, NIMH.nih.gov/Statistics/Index.shtml; South Carolina Department of Mental Health, State.sc.us/DMH/Anorexia/Statistics.htm; National Eating Disorders Association, NationalEatingDisorders.org