Key Clinical Questions
When should a hospitalist suspect an eating disorder? What questions aid in making the diagnosis? What screening tests are indicated?
When is emergent hospitalization warranted?
What are the complications of starvation and of binge/purge behaviors?
What is refeeding syndrome?
What are the evidence-based treatments for eating disorders?
What ethical considerations are specific to the treatment of eating disorders?
Medical morbidity associated with eating disorders is high; most hospitalists will encounter patients with these disorders, so knowledge of the presentation, natural history, complications, and medical management of these conditions is important. Patients with eating disorders may be admitted through emergency rooms in the setting of an acute event such as syncope or a seizure, or referred by their primary care provider for an abnormal electrocardiogram or for laboratory values warranting admission for medical monitoring and stabilization. The majority of patients are likely to have anorexia nervosa (AN), but some may have bulimia nervosa (BN). Others may present with an atypical eating disorder in which abnormal eating behavior is not associated with drive for thinness or fear of being fat.
Eating disorders are best thought of as disorders of motivated behavior and are similar to addictions. As with substance abuse disorders, patients exhibit a narrowing of their behavioral repertoire. They develop increasingly driven ritualized behaviors and progressive functional impairment. The vast majority of affected individuals are females with the lifetime prevalence of AN and BN in women estimated at 0.9% and 1.5%, respectively. Although less common in males, it is also the case that males with eating disorders are less likely to reach medical attention, and community rates of eating disorders in men and boys are higher than the 10% male gender prevalence observed in clinical samples. Mortality for AN is one of the highest amongst psychiatric conditions, with sixfold increase in standardized mortality rates.
As eating disorders are motivated behavioral conditions, ambivalence toward and frank avoidance of treatment are common. Patients may conceal their behavior from others and avoid professional help, complicating both diagnosis and management. When they do present for treatment, they are frequently in crisis, seeking assistance in managing complications of their disorder, or because they are brought to treatment by others. Half of all the community cases of AN and BN are undetected, underscoring the importance of recognizing signs and symptoms. Once identified, most patients are reluctant to engage in treatment, preferring treatment on their own terms, picking and choosing interventions that feel best, rather than those that may be best for them. Knowing how to engage patients to seek effective treatment is one of the most important challenges for the clinician.
INDICATIONS FOR EMERGENT HOSPITALIZATION
Medically unstable patients with eating disorders are ideally treated by a multidisciplinary team on a dedicated inpatient specialty unit, using a rehabilitative approach (including intensive behavioral and group therapy). Such programs are effective in restoring weight ...