My Doctor Online The Permanente Medical Group

Symptoms

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Persons suffering from an eating disorder may closely watch what they eat and their weight. They may also frequently have a distorted body image. For example, they may see themselves as overweight when they are actually below their normal weight or even suffering from starvation. A person may suffer from an eating disorder and still be within a weight range that is "normal" but may be experiencing dangerous behavior, such as purging.

A person suffering from an eating disorder may prefer to eat alone so that no one is watching how much or how little she eats. She may also eat regularly but is not able to maintain a healthy weight. The person may push food around her plate but never eat much of a meal. Or she may eat a normal or large amount of food and then purge the food by self-induced vomiting or other means.

For young women, the irregularity in weight may also result in delay of onset of periods (menarche) or a condition known as amenorrhea, the stopping of the menstrual period. Amenorrhea is usually temporary, and the menstrual period returns when the person begins eating a nutritious diet and restores sufficient amounts of weight. 

Psychological conditions, such as depression, anxiety, and obsessive-compulsive disorder (OCD) behaviors, may accompany eating disorders. These behaviors sometimes appear before the eating disorder, or they can occur along with an eating disorder and may make the eating disorder more difficult to treat.

In addition, some of the most common symptoms and behaviors of anorexia nervosa include:

• Extreme fear of gaining weight
• Significant weight loss or lack of expected weight gain
• Excessive exercising
• Distorted body image
• Secretive behaviors, such as layering clothing to hide thinness
• Loss of menstrual period (also known as amenorrhea) or delay of menstrual onset
• Low blood pressure, low or irregular pulse, or low body temperature
• Fatigue or frequent infectious illnesses 

Unlike with anorexia, an individual dealing with bulimia nervosa may not appear extremely thin. This is because a person with bulimia may engage in binge eating (eating excessive amounts of food), before purging the excess food. In addition, the most typical symptoms and behaviors of bulimia include:

• Binge eating in secret
• Repeated cycles of gaining and losing weight
• Tooth enamel erosion and tooth decay from self-induced vomiting
• Scratches or bite marks on the tops of the hands from inducing vomiting 
• Frequent bathroom use
• Self-induced vomiting
• Laxative and diuretic (water pill) use
• Sore, swollen throat resulting from frequent vomiting
• Bloated belly due to malnutrition

Binge eating disorder is similar to bulimia in some ways but does not include the purging associated with bulimia. Other common symptoms and behaviors of binge eating disorder include:

• Eating rapidly, usually finishing before anyone else
• Feeling uncomfortably full or sick after meals
• Hiding or stockpiling food, such as candy
• Eating alone or in secret and feeling shame
• Being overweight or obese

Risk Factors

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While we are still learning about the causes of eating disorders, we do know that they usually begin during adolescence. Young women experience eating disorders more frequently than young men, though young men can also suffer from them.

Eating disorders tend to run in families, although you can develop an eating disorder even if no one else in the family has been diagnosed. Living in a culture that overvalues a thin appearance also increases the risk.

People who struggle with low self-esteem, body image issues, or psychological conditions (such as depression) are at higher risk of developing an eating disorder. Having a history of physical or sexual abuse may also increase the risk in some people. Certain activities that may emphasize weight or appearance (ballet, wrestling, swimming, modeling) can also put people at risk for developing an eating disorder.

Sometimes, a stressful event or continued stress, depression, or anxiety can trigger an eating disorder. It can be an attempt to take control of a set of circumstances that may otherwise be difficult to control, such as family, school, or social problems.

A person does not have to experience all of the risk factors to develop an eating disorder. Each person's unique personality, coping skills, and support system may affect his or her risks.

Diagnosis

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During the clinic visit, we will assess the person's physical and mental health before diagnosing an eating disorder. While there are no specific laboratory tests available to diagnose an eating disorder, we can make a diagnosis based on symptoms. A proper assessment includes a medical history and physical exam, including a check of weight and height. We may also ask about eating and exercise behaviors to see if they are within normal ranges. Blood tests and an ECG (heart rhythm test) may be necessary to assess one's nutritional state and overall health.

Since malnutrition commonly occurs with eating disorders, we will also check for physical signs that involve heart rate or blood pressure, as well as examine the teeth, skin, hair, and nails for normal growth. We may order an X-ray to ensure that the bones are healthy and not losing minerals. If we suspect further complications from an eating disorder, we may order additional tests to check for heart and kidney problems.

Psychological health

Because psychological conditions, such as depression and anxiety, often accompany eating disorders, we also evaluate mental health status.

We may ask about sleeping and eating patterns, sadness, anxiety, and stress levels. Typically, we assess eating habits, exercise routine, and the person's feelings about her current health status. We may want to know about thoughts on body image. If a young woman is suffering from an eating disorder, we may ask about the regularity of her menstrual cycle.

Often, people with eating disorders are secretive about their eating patterns, so we might ask further questions such as:

• Do you vomit after eating to feel better?
• Do you feel distressed after eating?
• Do you eat in secret or hoard food?
• Do you take laxatives or diuretics?

Because people with eating disorders are quite good at hiding the signs, identifying an eating disorder can be difficult. If you suspect an eating disorder, contact us for an evaluation. The longer the person goes without treatment, the more challenging it may be to successfully treat the eating disorder. 

Treatments

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Eating disorders can be difficult to treat, especially because the person with the condition usually does not want treatment. Relapse is common. We typically treat eating disorders with psychological counseling, nutritional counseling, and, if needed, medications.  

Psychotherapy

Psychological counseling is an important part of treatment. It is crucial that the person attend regularly scheduled counseling sessions. The purpose of psychological counseling is to identify the emotional issues that may have triggered the eating disorder and to learn better coping skills. Several types of counseling may be used for treating eating disorders:

• Family therapy is considered the primary treatment for most adolescents with eating disorders. The goal is to teach family members how to best help their loved one and to discuss family relationships.
• Behavioral therapies, such as cognitive and interpersonal therapies, may help the person change her thought patterns to learn more positive, healthy ways of coping or may help her understand and gain control over her impulsive destructive behaviors.
• Group therapy shares similar challenges with others who have eating disorders and to gain group support.
• Individual therapy may help the person work through her own specific issues, including relationship issues.

Nutritional counseling

Nutritional counseling is another important part of treatment. It teaches the person the value of eating well-balanced meals. During nutritional counseling, the person may keep a daily food diary and also learn about basic nutrition, how to plan daily menus, and how to set reasonable goals for reaching, or accepting, a healthy weight. The goal of nutritional counseling is to help the person, over time, become responsible for her own healthy eating.

Medications

Using an antidepressant, such as fluoxetine (Prozac), might reduce the binging cycles in bulimia nervosa and binge eating disorder, although this research is ongoing. We might also prescribe medications to treat symptoms of depression, anxiety, or obsessive-compulsive behaviors that often accompany an eating disorder. Medications most often used include:

• Antidepressants, such as fluoxetine or sertraline (Zoloft), to treat depression, anxiety, and obsessive-compulsive behaviors. For teens and children, fluoxetine may be the most effective medication to treat depression.
• Mood stabilizers, such as valproic acid (Depakote), to treat mood swings and anxiety.
• Atypical antipsychotics, such as olanzapine (Zyprexa) or quetiapine (Seroquel), to reduce agitation, anxiety, and irrational thinking associated with eating behaviors.
• Anticonvulsants, such as topiramate (Topamax), to reduce binging.
• Nutritional supplements, including vitamins and minerals, as they may be required to help treat any complications from malnourishment.

It is important to closely monitor a child or teen who is taking an antidepressant or an anticonvulsant, especially during the first few weeks of treatment. In a small number of children and teens, these medications may increase suicidal thoughts and behaviors, although they are much more likely to help than to make matters worse.

For Caregivers

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Taking care of your child or teen with an eating disorder can be challenging. The person may be secretive, defensive, and not willing to seek treatment. The solution may seem simple: If the person would only eat properly or stop vomiting after meals, she might get better. But merely telling a person with an eating disorder to "eat healthy and get better" is not effective because the underlying issues are not about food. The issues are psychological, emotional, and physical in nature and must be addressed with proper treatment.

As a parent or caregiver, you may need to be extra patient during treatment, as it can take months, or even years in severe cases, for your child to recover from an eating disorder.

Family counseling may help provide tools on how to properly care for your child and may also provide you with some needed support. You might also choose to receive individual counseling to support your own needs while you are caring for someone with an eating disorder.

Your Child's Care with Me

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The Child and Adolescent Services in the Department of Psychiatry offer a variety of mental health services. We hope you will not hesitate to call us, for advice or to arrange for services, if your child appears to be troubled or suffering in some way.

Your child’s treatment plan, based on an assessment of his or her needs, may include health education, individual, family, or group interventions, and, sometimes, medication, as appropriate. If your child should need chemical dependency services, these are available within our department as well.  Your child’s emotional health is related to the quality of his or her physical health, family life, and social and academic experiences. The mental health professionals in the Child and Adolescent Psychiatry Clinic encourage the promotion of health in all these realms.

If you are concerned about your child’s symptoms, please call our clinic to speak with a therapist, during the hours of 8:30am- 5:30pm, Monday through Friday. After hours and on weekends, for urgent matters, you may call our clinic number and you’ll be connected to our Regional Psychiatry Call Center, where you will be assisted by a mental health professional. If you believe you have a medical or psychiatric emergency, please call 911 or go to your nearest emergency room.

Whether by phone or in person, we will discuss your child’s symptoms and address your concerns. Together we will create a treatment plan to help your child and your family.

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After our first visit, you can connect with me in a variety of ways, depending on the situation and what is most convenient for you at the time. I am available online, by telephone, or in person.
 
For nonurgent questions or concerns, you can e-mail me using this site, once you have set up access to manage your child’s health. Use the Manage Your Family’s Health links to get started. If you are a teen, you may e-mail me directly as well.

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Coordinating Your Child's Care

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Having all of our Kaiser Permanente departments located together or nearby, including pharmacy, laboratory, radiology, and health education, makes getting care for your child easier.

Another major benefit is our comprehensive electronic medical record system, which allows all of the doctors and clinicians involved in your child’s care to stay current on your child’s health status and to collaborate with each other as appropriate.

When every member of the health care team is aware of all aspects of your child’s condition, care is safer and more effective.

If you come to an office visit

• At the end of your child’s visit, you may receive a document called the “After Visit Summary” that will summarize the issues we talked about during the visit. You can refer to it if you forget what we discussed, or if you just want to recheck your child’s height, weight, or vital signs. (If your child is under age 12, you can also view these summaries online, under Past Visits.)
• To help you prepare for your visit, please see additional details under Office Visit.

If medications are prescribed

Your child’s therapist and psychiatrist will work together to monitor and assess how your child’s medications are working and the psychiatrist will make adjustments as needed.

Prescriptions can be filled at any Kaiser Permanente pharmacy. Just let us know which pharmacy works best for you, and we will send the prescription electronically, in advance.

If refills are needed in the future, you can:

• Order them online or by phone. Order future refills from my home page or by phone using the pharmacy refill number on your prescription label.
• Have them delivered to you by mail at no extra cost. Or you can pick up your child’s medications at the pharmacy.
• If no refills remain when you place your order, the pharmacy will contact us regarding your prescription.

If lab testing or imaging is needed

For lab tests, we use our electronic medical record system to send the requisition to the Kaiser Permanente laboratory of your choice. For imaging procedures, such as X-rays, we will schedule an appointment with the Radiology Department.

When the results are ready, we will contact you with the results by letter, secure e-mail message, or phone. In addition, you can view most of your child’s laboratory results online, along with any comments that may be attached to explain them.

If we refer your child to a specialist

My specialty colleagues are readily available to assist if we need additional advice about your child’s condition. In some cases, they may be contacted during your visit, so we can discuss your child’s care together. If we decide your child needs a specialty appointment after that discussion, we can often schedule it the same day or soon thereafter.
 

Convenient Resources for You

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As your child’s mental health professional, I have a goal to provide high-quality care and to offer you choices that make your child’s health care convenient. I recommend that you become familiar with the many resources we offer so that you can choose the services that work best for you.

My Doctor Online is available to help you manage your family’s care at any time that is most convenient for you. You can also learn how to coordinate care for the ones you love from my home page.

Manage your family’s health

Take a few minutes to set up access to act on your child’s behalf. Then you can use my home page to:

• View and compose secure e-mail messages.
• Manage your child’s prescriptions and refills.
• Schedule well visit and nonurgent primary care appointments.
• View your child’s preventive services to see whether your child is due for any immunizations or well visits.
• If your child is under 12, you can also view most lab test results and review information about past visits.

If you need help doing the things listed above, check the "Learn how" page. From there, you can learn tips and tricks on how to manage your child’s health conveniently.

Learn more about your child’s condition

• Read about causes, symptoms, treatments, and procedures.
• Find interactive health tools, videos, and podcasts to help you manage your child’s condition.
• View programs to help you decide on or prepare for a surgery or procedure.

Help your child stay healthy

• Sign up for our online newsletters for parents, customized to your child’s age.
• Locate health education classes and support groups offered at our medical center.
• Explore interactive programs, videos, and podcasts that focus on helping you keep your child healthy.
• View your child’s Preventive Services to see whether he or she is due for any immunizations or a well visit (checkup).
  

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