Crit Care Nurs Clin N Am 16 (2004) 515 – 530

Eating disorder emergencies: understanding the medical

complexities of the hospitalized eating disordered patient
Martina M. Cartwright, PhD, RD*
Lilly Research Laboratories, Eli Lilly & Company, Indianapolis, IN 46285, USA

At any given time 44% of American women
and 20% of men are on a weight-loss diet [1]. The
United States is a weight-obsessed nation, spend-
ing $33 billion on weight-loss products, programs,
and pills every year [2]. When the desire for thin-
ness or bhealthQ becomes an obsession, the result is
often disordered eating patterns and perhaps an
eating disorder.
What are eating disorders?
Who is most likely to develop an eating disorder?
Eating disorders can affect people of all ages, but
86% are afflicted before the age of 20 years [3,4]. In
general, eating disorders occur in adolescence and
young adulthood; however, diagnosis in children
under 12 years is possible [5 – 7]. More than 90%
of eating disorders occur in females, but disordered
eating patterns affect a number of males [8]. Person-
ality disorders and depression are common findings
in patients with eating disorders [9 – 11].

Eating disorders are a spectrum of serious mal-

adaptive eating behaviors characterized by severe
What causes an eating disorder?
body image distortions, extreme or unhealthy food in-
take patterns, and psychologic issues. Eating disorders
The causes of eating disorders remain a mystery,
typically develop in adolescence and early adulthood,
but genetic, physiologic, psychologic, and environ-
affecting more females than males. Psychiatric con-
mental and social factors are thought to contribute
ditions such as depression, anxiety, and personality
(Fig. 1) [4,12]. Disordered eating behaviors are
disorders often coexist with eating disorders, as do
frequently associated with psychologic maladies and
comorbid conditions such as cystic fibrosis, insulin-
comorbid conditions [13].
dependent diabetes mellitus (IDDM), and irritable
Genetic factors seem to play a role in the devel-
bowel syndrome. Serious physiologic consequences
opment of an eating disorder. Many experts believe
associated with eating disorders cause medical com-
that there is an inherent predisposition to disordered
plications that require frequent visits to the emergency
eating because the co-occurrence of eating disorders
room and subsequent treatment in the ICU. This
in identical twins is greater than that in fraternal twins
article reviews the pathology of eating disorders and
[14,15]. Additionally, genetic factors seem to influ-
discusses the complexities associated with treating the
ence neurochemistry; serotonin, endorphins, and
serious medical complications of such patients.
norepinephrine levels are reduced in patients with
eating disorders [16 – 19]. Decreases in these neuro-
chemicals are associated with depression, decreased
physical and emotional satisfaction, and reduced
satiety after meals.
* 8019 East Via Costa, Scottsdale, AZ 85258. Patients with eating disorders typically have
E-mail address: drmartinac@aol.com elevated cortisol and vasopressin levels; high levels

0899-5885/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccell.2004.07.002 ccnursing.theclinics.com
516 M.M. Cartwright / Crit Care Nurs Clin N Am 16 (2004) 515 – 530

diminished in persons with eating disorders and may

Fig. 1. Factors contributing to an eating disorder.
of these agents are associated with stress. Experts
theorize that cortisol and vasopressin levels corre-
late with the emotional distress often observed in suf-
ferers of eating disorders [16 – 19]. Moreover, levels
of cholecystokinin (CCK), an important mediator
of satiety, are decreased in some eating disorders
[20,21].
Abnormal levels of neurochemicals and satiety
mediators are linked to physiologic factors that
regulate mood and appetite. Serotonin, norepineph-
rine, endorphins, and CCK are often significantly
lead to disordered eating patterns [16 – 21]. Eating
disorders tend to develop in adolescence because
this age group is prone to emotional fluctuations and
influences. The line between physiologic hunger
and psychologic hunger is often blurred, and some
adolescents eat, and perhaps binge, in response to
emotional triggers instead of physiologic cues. Others
practice restrictive dieting and ignore physiologic
hunger in an effort to reduce weight, gain a feeling of
control, or to meet social, cultural, or other expecta-
tions. Not all adolescents who have disordered eating
patterns develop a full-blown eating disorder. Those
with personality or other psychologic maladies are
most at risk.
Many experts believe that eating disorders are
akin to other dependency-driven behaviors [9,10].
For example, using food, binging, or restrictive diet-
ing to cope, calm, soothe, or detract from overwhelm-
ing emotional distress is similar to the use of alcohol
for the same reasons. Disordered eating provides a
false sense of control. Eating disorder victims tend
to have similar personality traits including low self-
esteem; depression, loss of control, feelings of worth-
lessness, poor family communication, or lack of
coping mechanisms [9,10].

Eating
Disorder

Disordered Eating

Excessive Dieting

Successful diet with weight loss

Weight loss dieting

Desire for weight loss

Fig. 2. Proposed progression of the development of an eating disorder. Eating disorders begin with a desire to lose weight
and subsequent weight loss. If the diet is successful and coincides with a traumatic life event, emotional upheaval, or other
risk factors (eg, psychiatric conditions, comorbid disease states), the person is likely to progress to the next level of excessive
dieting. With positive reinforcement (eg, compliments regarding weight loss after being overweight), severe distorted eating
behaviors and ultimately an eating disorder may develop. Data from Fisher M. Anorexia and bulimia nervosa in adolescents.
In: Nutrition Week program syllabus for the annual meeting of the American Society of Parenteral and Enteral Nutrition
Balitmore, MD: Aspen, vol. 2. p. 661 – 7.
 M.M. Cartwright / Crit Care Nurs Clin N Am 16 (2004) 515 – 530
Eating disorders often manifest following a
traumatic life event that has left a feeling of power-
lessness. A significant number of eating disorder
sufferers have experienced a period of being over-
weight, teasing regarding weight, or a sense of social
isolation [4,12,22]. First attempts at weight loss are
frequently met with compliments and praise from
others. Weight loss then becomes a source of positive
reinforcement, and losing weight, even to extremes,
develops into an obsession (Fig. 2) [23].
Cultural issues: the power of thinness
Environmental and social factors influence and
reinforce the practice of eating disorders.
Cultural ideals of beauty strongly influence the
behaviors of those who most desire to be socially
accepted. Today’s adolescents are bombarded with
images of extreme thinness. In Western culture, thin-
ness is equated with beauty, happiness, wealth, and
popularity. A typical beauty queen of 1950 was
50400 tall and weighed 140 pounds; today she is 501000
tall and weighs 110 pounds [24]. In a recent survey,
55% of adolescents were terrified of being obese, and
39% were on restrictive diets [5]. Astonishingly, 40%
to 50% of 9-year-olds were dieting for weight loss,
and many were encouraged to do so by their mothers
[6,25]. Negative family influences, particularly pater-
nal comments and dieting habits, strongly influence
self-esteem, body image, and eating behaviors
[25 – 27]. Dieting and body dissatisfaction have
become the norm for many adolescents.
Occupational hazards
Adolescents or young adults who develop eating
disorders are often involved in high-risk activities—
those that value thinness. An estimated 62% of fe-
males involved with bappearance sportsQ such as
gymnastics, figure skating, ballet dancing, and track
suffer from disordered eating behaviors [28,29].
Males are not exempt; 5% to 15% of all males with
eating disorders are involved in track, wrestling, or
acrobatics, are jockeys, or are in the military [8,28,
30,31]. Males with disordered eating typically par-
ticipate in more hidden binge eating behavior and
extreme exercise than females [28,30]. Actors and
models of both genders frequently practice eating
disorder behaviors.
Regardless of gender, those with eating dis-
orders share common behavioral traits: the desire
517
for control, perfectionism, and a high value placed
on thinness.
Common behavioral traits
Persons with eating disorders adhere to a highly
selective diet consuming foods they believe are
bgoodQ or bsafeQ and avoiding foods that are
bforbiddenQ or bbad.Q Most have an extensive history
of dieting, with or without successful weight loss,
and severely limit their food intake for short or
long periods. Weight is frequently measured, and life
stressors usually precipitate dieting, marked weight
changes and altered behavior. Persons with eating
disorders often have a psychiatric history including
mood, anxiety, or personality disorders and substance
abuse [9,10]. Some have suffered physical, emo-
tional, or sexual abuse as well [10,32].
Types of eating disorders
There are three main categories of eating disor-
ders: anorexia nervosa, bulimia nervosa, and eating
disorders not otherwise specified (EDNOS); the last
category includes compulsive overeating and binge
eating disorder. Another disordered eating pattern,
orthorexia nervosa, has been identified but has not
been classified as a true eating disorder.
After asthma and obesity, anorexia nervosa is the
third most common cause of chronic illness in ado-
lescent females [3]. Anorexia nervosa is character-
ized by a refusal to maintain a normal body weight,
an intense fear of gaining weight, amenorrhea, a
severely distorted body image, and a body weight
that is more than 15% lower than the ideal. There are
two subtypes of anorexia nervosa: restricting and
binge/purge. The latter is characterized by binging
followed by self-induced vomiting, laxative abuse,
or other inappropriate weight control measures while
still meeting the criteria for anorexia nervosa (Box 1)
[33,34].
Anorexia nervosa is a Western phenomenon, and
an estimated 0.5% to 3.7% of American females will
suffer from anorexia nervosa in their lifetime [28].
Among psychiatric disorders, anorexia nervosa has
one of the highest mortality rates, estimated to be
0.56%/year or 5.6%/decade [35,36]. The most com-
mon causes of death are cardiac arrest, electrolyte
imbalances, and suicide.
The causes of anorexia nervosa are unknown, but
physiologic, psychologic, environmental, cultural, ge-
netic, and familial factors may play a role. Anorexics
518 M.M. Cartwright / Crit Care Nurs Clin N Am 16 (2004) 515 – 530

food constantly and have a strong desire to control

Box 1. DSM IV criteria for anorexia
and to be liked; they tend to be perfectionists who
nervosa [33]
like extreme structure. Rigid diets, obsession with
weight, extreme and regimented exercise routines,
A. Refusal to maintain body weight at
and a host of mood changes are frequently observed
or above a minimally normal weight
in these patients. Thinness becomes a source of
for age and height (eg, weight loss
pride and competition. To this end, there are now
leading to a maintenance of body
several bpro anaQ websites thorough which adoles-
weight 15% below the expected
cents share tips on becoming anorexic and ways
or failure to make expected weight
to hide anorexia from parents, physicians, and
gain during a growth period, lead-
others. These sites frequently post competitions for
ing to body weight 15% below
the bflattest belly.Q One young female in treatment
the expected)
for anorexia was actively posting tips on how to
B. Intense fear of gaining weight or
manipulate caregivers. These patients, and often their
becoming fat, even though under-
families, can be difficult to deal with in the in-patient
weight.
hospital setting.
C. Disturbance in the way in which
one’s body weight, size, or shape
is experienced (eg, the person
claims to bfeel fatQ or believes
History of anorexia nervosa
that one area of the body is btoo fatQ
even though the individual is
Early religious writings describe what is likely
clearly underweight)
anorexia nervosa. Scholars believe that St. Catherine
D. In females, absence of at least three
of Siena developed anorexia nervosa and died of
consecutive menstrual cycles
it in 1380 [37]. She is often considered an icon
by young girls suffering from anorexia nervosa.
Restricting type
The first medical account of anorexia nervosa was
recorded in 1689 by Morton [38]. He described two
During the current episode of anorexia
anorexic patients, one an 18-year-old female, the
nervosa, the person has not regularly
other a 16-year-old male. Morton treated both with
engaged in binge eating or purging behav-
herbal therapies and recommended a change in
iors such as self-induced vomiting or the
environment for the male patient, allowing him to
misuse of laxatives, diuretics, or enemas.
escape his controlling family. Two London physi-
cians described similar cases in the 1760s [39].
Binge/purge type
In 1873, two notable physicians, Lasegue [40] of
Paris and Gull [41] of London, separately described
During the current episode of anorexia
anorexia nervosa. Lasegue’s paper On Hysterical
nervosa, the person has regularly engaged
Anorexia detailed the psychopathology of anorexia
in binge eating or purging behaviors.
nervosa with physical symptoms of amenorrhea,
wasting, dry skin, anemia, and heart murmurs [40].
Gull’s report briefly described three teenaged girls
tend to have high cortisol levels that may affect with anorexia nervosa who were treated with small
mood and appetite [19]. Many anorexics have avoid- frequent meals [41]. In an 1888 volume of Lancet,
ant or dependent personalities characterized by per- Gull described a 14-year-old with anorexia nervosa
fectionism, emotional or sexual inhibition, and a whose treatment was blight food every few hours
bgood or perfectQ image [9,10]. Most are terrified administered by a nurseQ [42]. Literature from the
of ridicule, loneliness, and failure. Anorexics tend to late 1960s to 1980 recognized that self-starvation
be high performers in school, athletics, and other reflects a desire for autonomy, control, and self-
activities. As many as 69% of anorexics have ob- respect in an attempt to cope with fears of maturity
sessive-compulsive disorder and suffer from panic [39,43]. Russell [44] highlighted the fear of fat-
attacks and phobias [9,10,23]. The primary phobia is ness as central to the pathophysiology of anorexia
that of becoming fat. nervosa and emphasized the importance of an ex-
Anorexia nervosa often begins as normal dieting perienced nursing staff in treating the anorexia ner-
that progresses into an obsession. Anorexics think of vosa patient.
 M.M. Cartwright / Crit Care Nurs Clin N Am 16 (2004) 515 – 530
Box 2. DSM IV criteria for bulimia nervosa
[33]:
A. Recurrent episodes of binge eating.
A binge episode is characterized by
both of the following:
1. Eating, in a discrete period of
time, usually within a 2-hour
period, an amount of food that
is definitely larger than most
people would eat during a similar
period of time and under simi-
lar circumstances
2. A sense of lack of control over
eating during the episode such
that the person feels unable to
stop eating or to control what or
how much is consumed
B. Recurrent inappropriate compensa-
tory behaviors to prevent weight
gain, such as self-induced vomiting;
misuse of laxatives, diuretics, ene-
mas, or other medications; fasting;
or excessive exercise
C. The binge eating and inappropri-
ate compensatory behaviors both
occur, on average, at least twice a
week for 3 months
D. Self-evaluation is strongly influ-
enced by body shape and weight
E. The disturbance does not occur
exclusively during episodes of ano-
rexia nervosa
Purging type
During an episode of bulimia nervosa,
the person has regularly engaged in self-
induced vomiting or the misuse of laxa-
tives, diuretics, or enemas.
Nonpurging type
During the current episode of bulimia
nervosa, the person has used other com-
pensatory inappropriate behaviors such
as fasting or excessive exercise but has
not regularly engaged in self-induced
vomiting or the misuse of laxatives, diuret-
ics, or enemas.
519
Bulimia nervosa
Bulimia nervosa, often called bcollege girl dis-
ease,Q is the most common eating disorder, affecting
1% to 4% of females in the United States and 19% to
30% of college-aged women [4,28]. It is estimated
that 1.1% to 4.2% of American females will suffer
from bulimia nervosa during their lifetime [28]. Bu-
limia nervosa generally starts as a strategy to con-
trol weight but develops into a preoccupation with
eating, purging, and weight. Bulimia nervosa is
characterized by binge eating, which is consuming
a large amount of food/calories in a short period
of time. Sometimes the binges last all day; for
others, binges last 1 to 2 hours. Large binges up to
20,000 calories have been reported, although the
average binge is 2000 to 5000 calories [33]. Binging
episodes are followed by inappropriate compensatory
behaviors (purging) to prevent weight gain; these
methods include self-induced vomiting; abuse of laxa-
tives, diuretics, enemas, particular herbal remedies,
diet pills, and proemetics; prolonged fasting; and ex-
cessive exercise (Box 2) [33].
Most bulimics are of normal weight or are slightly
overweight, but they fear gaining weight and have
profound body dissatisfaction. Bulimics tend to be
more impulsive and emotionally uncontrolled than
their counterparts with anorexia nervosa [9,23,28].
An estimated 40% have borderline personality dis-
order characterized by unstable moods, fear of
abandonment, inability to be alone, and anger control
issues [9]. About 30% suffer from obsessive-com-
pulsive disorder [9,23,28].
History of bulimia nervosa
In 1979, the term bbulimia nervosaQ was coined to
describe episodic overeating that is accompanied by
compensatory behaviors and a fear of fatness.
Historically, overeating followed by compensatory
strategies can be traced back to the ancient Egyp-
tians and Europeans of the Middle Ages who used
binge/purge cycles to treat a variety of ailments [45].
Vomitoriums were common in ancient Rome, and
two Roman emperors, Claudius and Vitellus, both
had preoccupations with extravagant consumption
followed by habitual purging. Bulimic behavior by
several Christian saints is also well documented [37].
Although such historic binge/purge behavior may
mimic modern eating disorders, the fear-of-fatness
criterion is absent.
Janet [46] published the first case of bulimia
nervosa that meets modern criteria in 1903. Similar
520 M.M. Cartwright / Crit Care Nurs Clin N Am 16 (2004) 515 – 530

Table 1 Table 1 (continued)

Medical complications associated with eating disorders Anorexia Nervosa
[3,19]:
Purging- Restricting- Bulimia
Anorexia Nervosa
System type type Nervosa
Purging- Restricting- Bulimia B vitamin deficiencies +
System type type Nervosa Fat-soluble vitamin +
Electrolytes/renal system deficiencies
Volume depletion + + + Skeletal system
Hyponatremia + + Osteopenia ++
Hypokalemia ++ ++ Osteoporosis ++
Hypophospatemia + + + Low estrogen ++
Metabolic alkalosis + + Thyroid impairment ++
Elevated BUN + + + Cold intolerance ++
Renal failure + + ++ Skin and hair
Cardiovascular system Lanugo ++
Bradycardia + Yellow tint to ++
Hypotension + skin/scalp hair
Reduced blood flow + Russell’s sign + ++
Heart murmurs + Poor wound healing ++
EKG anomalies + Neurologic symptoms
Elevated cholesterol + EEG anomalies ++
Cardiomyopathy + + Abnormal brain ++
Pulmonary system images
Aspiration pneumonia + + + Psychologic traits
Pneumothrorax + + + Avoidance + +
Hematologic system Dependency + +
Leukopenia + Borderline personality +
Thrombocytopenia + Impulsivity +
Bone marrow atrophy + Obsessive-compulsive ++ ++ +
Impaired immune + disorder
function Abbreviations: BUN, serum urea nitrogen; CCK, cholecys-
Gastrointestinal system tokinin; +, observed in some eating-disorder patients; ++,
Salivary gland + + ++ observed in many eating-disorder patients.
hypertrophy Data from NIH Office of Research on Women’s Health.
Tooth erosion + ++ Eating disorders: fads and facts. 1998. Available at: www.
Delayed gastric + nimh.nih.gov. Accessed: March 13, 2003; Mitchell JE,
emptying Pomeroy C, Adson DE. Managing medical complications.
Sore throat + ++ In: Garner DM, Garfinkle BT, editors. Handbook of treat-
Esophageal rupture + ++ ment of nervous disorders. 2nd edition. New York: Gulliford
Esophageal + ++ Press; 1997. p. 383 – 93.
lacerations
Gastrointestinal + ++
bleeding cases by Wulff in 1932 [47] and Biswanger in 1944
Pancreatitis ++ and 1945 [48] followed, each describing a young
Constipation + + + woman who was fearful of becoming fat, suffered
Metabolic system from powerful cravings, and induced vomiting. Such
Amenorrhea ++ case reports became more frequent in the 1970s and
Elevated carotene + continue today in what is recognized as bulimia
Elevated cholesterol +
nervosa [49].
Elevated cortisol + + +
Low serotonin + + +
Low CCK + ++
Low endorphins + ++ Medical complications of anorexia and bulimia
Low epinephrine +
Low blood glucose + Patients with anorexia nervosa and bulimia
Trace mineral + nervosa often present to a variety of health care
deficiencies practitioners including physicians, counselors, psy-
Zinc and copper + chologists, and the emergency room staff, but eating
 M.M. Cartwright / Crit Care Nurs Clin N Am 16 (2004) 515 – 530
disorders are rarely diagnosed in the emergency
room. In a recent study of 122 patients with an eat-
ing disorder admitted to a psychiatric emergency
room, 44.3% were diagnosed with anorexia nervosa,
34.4% with bulimia nervosa, and 21% with EDNOS
[50]. Most were female, with an average number of
1.74 emergency room visits over a 5-year period [50].
Patients with anorexia nervosa often develop
serious medical complications associated with pro-
longed starvation. The clinical profile of a patient
with anorexia nervosa is similar to that of other
starved patients with some notable exceptions. Many
anorexics claim that their energy level is normal or
high, and they often minimize the severity of the
disease. In contrast, bulimic patients often feel tired
and depressed, and they acknowledge the severity of
their illness. Both anorexics and bulimics suffer from
profound metabolic and functional disabilities re-
lated to prolonged starvation and binging/purging
behaviors (Table 1) [19].
Fluids/electrolyte and renal system complications
Electrolyte anomalies, including hypokalemia,
hypocalcemia, hypophosphatemia, hyponatremia,
and hypomagnesemia, are common in the purging
anorexic and bulimic [19,51]. Dehydration from
chronic emesis and laxative and diuretic overuse
can lead to volume depletion and result in orthostatic
hypotension, syncope, and chronic headaches. Meta-
bolic alkalosis is a frequent finding.
Renal and electrolyte anomalies have been re-
ported in up to 70% of patients with an eating
disorder, particularly in purgers [52]. Hypovolemia
and reduced glomerular filtration rate are seen in
anorexia nervosa and bulimia nervosa. Progressive
renal insufficiency and ultimately chronic renal fail-
ure have been observed in eating disorder patients
with chronic hypokalemia [19,52]. Elevated serum
urea nitrogen (BUN) and transient azotemia have
been observed in anorexia and bulimia. Fainting
and collapse are classic symptoms of eating disorders
and are common reasons for emergency room visits.
These symptoms often indicate serious cardiovascu-
lar complications.
Cardiovascular complications
Cardiovascular complications are frequent in
anorexia nervosa. Patients with anorexia nervosa
present with reduced blood flow, high cholesterol,
bradycardia, heart murmurs, and low blood pressure,
521
which persist despite restricted fluid volume. Mitral
valve prolapse often develops but is reversible with
weight gain. EKG changes occur in both anorexia
nervosa and bulimia nervosa, including prolongation
of the QT interval; life-threatening arrhythmias are
also seen. Loss of heart muscle mass may manifest
as decreased QRS amplitude and T wave changes.
Cardiomyopathy is a frequent finding and can result
from rapid overfeeding secondary to hypophos-
phatemia and starvation-induced muscle wasting;
however, it is most often associated with proemetic
ipecac toxicity [53,54]. Ipecac contains an alkaloid,
emetine, which is known to cause skeletal muscle
toxicity often leading to proximal muscle weakness
and cardiac arrest and is a significant cause of death
in bulimics and purging anorexics [19,53,54]. This
complication was the cause of death of Karen
Carpenter [23].
Pulmonary and gastrointestinal complications
Spontaneous pneumothorax and pneumomedias-
tinum have been observed in anorexia nervosa and
bulimia nervosa, even in those who do not vomit.
Aspiration pneumonia from recurrent vomiting is
rare. Changes in respiratory rate have been reported
but are variable.
Salivary gland hypertrophy has been described in
anorexics and more frequently in bulimics [19,51].
Recurrent vomiting leads to decreased saliva produc-
tion, xerostomia (dry mouth), and severe tooth de-
cay with significant erosion of the enamel and
dentin. The dentist is often the first health care
practitioner to diagnose a bulimic because profound
tooth decay is apparent on the molars and between
teeth [19]. Bulimics typically have a significant
dental history, requiring resin-bonded ceramic crowns
at an early age to treat severely eroded dentition.
Gingival recession, gingival bleeding, and abscesses
are common findings.
Bulimics and purging anorexics often complain of
sore throats, and many develop esophageal lacera-
tions. Esophageal rupture has been described and
is often a fatal complication [19]. Gastrointestinal
bleeding and severe constipation after years of laxa-
tive abuse have been noted. Delayed gastric empty-
ing is observed and is associated with postmeal
bloating in these patients until gradual refeeding
plans have been instituted [55 – 57]. Anorexics fre-
quently develop superior mesenteric artery syndrome,
a condition that occurs in very thin individuals and is
characterized by obstruction at the level of the third
portion of the duodenum [19]. The cause is unknown,
522 M.M. Cartwright / Crit Care Nurs Clin N Am 16 (2004) 515 – 530
but weight gain seems to correct the condition. Acute
pancreatitis is associated with bulimia nervosa and is a
cause of emergency room visits [4,19,23,50].
Hematologic complications
Anorexics present with an interesting hematologic
profile: leukopenia, mild anemia, thrombocytopenia,
low or normal serum albumin, and elevated choles-
terol and carotene. The last gives rise to the char-
acteristic orange appearance of the anorexic’s skin,
nails, and hair. Immune dysfunction related to poor
granulocyte function, impaired chemotaxis, and low
complement and immunoglobulin production has
been observed. Vitamin deficiencies are uncommon,
with the exception of B12 deficiency, which leads to
pernicious anemia. Bone marrow atrophy in severe
anorexia results in life-threatening anemia [19]. Low
serum zinc and copper are frequently observed and
may impair wound healing and taste acuity. Such
hematologic changes are rare in the bulimic patient.
Metabolic complications
Estrogen levels are generally low in anorexic
females, resulting in amenorrhea, infertility, reduced
bone density, and delayed sexual maturity [58,59].
Anorexic women who become pregnant are at higher
risk for miscarriage, for giving birth to a low-birth-
weight infant or one with birth defects secondary
to vitamin deficiencies, and for postpartum depres-
sion [13].
Thyroid function may be impaired in anorexia
nervosa, but thyroid-stimulating hormone and T4
levels are usually normal with reductions in T3. Cor-
tisol and growth hormone are typically elevated [19].
Bone health
More than 90% of women with anorexia develop
osteopenia, with 40% experiencing osteoporosis
[60,61]. Up to 65% of young females fail to develop
strong bones, and stunted growth has been observed
in anorexic males [60,61]. Bone loss is complex, but
in females, it is associated with low estrogen levels.
Other contributing factors include high cortisol, low
calcium, poor dietary intake, and low body weight.
Anorexic athletes and performers are often frequent
visitors to the emergency room for fractured toes and
fingers. Falls may also lead to fractures.
Skin and hair complications
Anorexics develop a fine, soft, downy hair on the
face, forearms, and other parts of the body called
lanugo. Lanugo is an adaptation to starvation de-
signed to help preserve body temperature because
loss of body fat insulation and hormonal changes lead
to cold intolerance. Anorexics frequently try to
remove or hide lanugo by shaving often and dressing
in long sleeves even in warm weather. Brittle nails,
dry skin, and loss of scalp hair are often seen in
anorexia. High carotene levels in anorexia nervosa
lead to discolored skin and scalp hair. Bulimics often
present with bRussell’s sign,Q a lesion located on the
back of the forefinger [45]. It is caused by repeated
exposure to stomach acid when the gag reflex is
initiated to induce vomiting.
Neurologic alterations
Structural changes in the brain and nervous sys-
tem resulting in abnormal activity have been docu-
mented [17,19]. Brain imaging has shown enlarged
ventricles and increased ventricle:brain ratios in ano-
rexia nervosa. These changes are generally referred
to as pseudoatrophy because the alterations resolve
with weight gain. Seizures, disordered thought pro-
cesses, and peripheral neuropathy are associated with
severe malnutrition in eating disorders. The presence
of these anomalies in a normal-weight bulimic sug-
gests significant malnutrition.
Medical complications requiring immediate
intervention
Premature death from eating disorders often
results from the previously discussed medical com-
plications or from suicide. It is difficult to predict
when death is imminent, because many die of sud-
den cardiac arrest; however, the following signs
and symptoms reflect a need for immediate medical
attention: sudden, rapid weight loss of more than
15 pounds in 4 weeks; syncopal episodes; seizures;
severe bradycardia; renal dysfunction reflected by a
urine output less than 400 cm3/day; dysrhythmias;
severe dehydration; tetany; or rapid decrease in
exercise tolerance or exercise-induced chest pain
[62]. Although emergent medical situations are easy
to identify when in progress, identifying impending
medical crises and predicting the rate of deteriorating
health proves challenging in these patients.
 M.M. Cartwright / Crit Care Nurs Clin N Am 16 (2004) 515 – 530
Clinical vignette one: the anorexic athlete
A dietitian is asked to assess the diets of 31 high-
endurance performers. Several performers routinely
smoke cigarettes and drink alcohol and several cups
of coffee per day. One performer stands out: M.F., an
18-year-old female, seems depressed. She wears
baggy, long-sleeved blouses and long pants in 100°
weather and often complains of feeling cold. Others
have noticed that M.F. appears very skinny, and she
shaves often; her endurance is poor, and she has
fainted during practices. M.F. has sores on the corners
of her mouth and has experienced several bone
fractures in her feet and toes. She often complains
of sore throats and is known to be bobsessed with
hard candy.Q
Her hair appears dry and falls out; her skin is
orange/yellow. M.F. admits to restrictive dieting and
using diet pills to control her weight, because her
job is dependent on her bstaying in shape.Q M.F.
is eventually treated in an outpatient eating dis-
orders facility.
Comments
M.F. is a classic anorexic. The physical signs
include lanugo, fainting, cold intolerance, and skin
discoloration. She tries to hide her body with baggy
clothes. She complains of frequent sore throats and
painful teeth—signs of purging. Anorexics often use
hard candy to decrease xerostomia and to raise blood
sugar. The sores at the corners of her mouth indicate a
vitamin deficiency.
Clinical vignette two: the anorexic male
C.W., a 21-year-old male Japanese college stu-
dent, was admitted to the emergency room after being
found unconscious at home. This was his fourth visit
to the emergency room in 3 months. He was found to
be dehydrated, bradycardiac, and hypokalemic. He
was transferred to the general medicine ward, because
beds in the psychiatric unit were not available. The
dietitian interviewed him. C.W. was 60 tall and
weighed 110 pounds. He admitted to restricting his
food intake to rice, an apple, and iced tea three times
a day. He refused to eat hospital food and demanded
only fruits and vegetables. C.W. frequently pulled out
his intravenous line. He was not being monitored on
the general medicine floor; the cleaning staff found
food hidden in his shoes, under the bed, and evidence
that food had been flushed down the toilet. Peanut
butter was scraped under the feeding tray. On day 3,
523
C.W. was transferred to the psychiatric unit and was
eventually discharged. Within 1 week of discharge,
he returned to the emergency room where he died of
cardiac arrest, probably from ipecac poisoning.
Comments
Eating disorders typically occur in women but are
becoming more frequent in men. C.W. had perfec-
tionist tendencies; he was a straight-A student and
admitted to being jealous of his sister’s academic
performance. He stated a lack of control over his
life’s direction. He had obsessive-compulsive tenden-
cies and was considered a bneat freak.Q
Clinical vignette three: the recovering bulimic
A.B. is a 21-year-old recovering bulimic visiting
the registered dietitian’s office for her monthly
follow-up appointment. Her previous medical history
includes bulimia nervosa of 3 years’ duration with
excessive binging, purging with laxatives and herbs,
self- and ipecac-induced vomiting, and anxiety
disorder. Last year A.B. entered an inpatient treat-
ment clinic and has been binge free, although she still
exercises obsessively. Her daily exercise routine now
includes 3 hours of swimming every morning from
5:00 to 8:00 a.m., weight training from 2:00 to
4:00 p.m., and running from 7:00 to 8:00 p.m. She
now consumes small frequent meals throughout the
day providing 2100 calories/day. She has done well
with psychotherapy. Today she is 10 minutes late for
her scheduled appointment and enters the office cov-
ered in vomit and crying. A.B. states that she bpurged
in the car after having a buffet with my parents. They
told me that my grades are too low.Q A.B.’s family has
been resistant to family therapy, particularly her
mother, who is a chronic dieter and former beauty
queen. The dietitian cleans up A.B. and calls the
psychologist for an immediate consultation. Two
weeks later, A.B. returns for a follow-up appoint-
ment. She is now receiving more intense psychother-
apy and has taken steps to become more independent
from her family.
Comments
A.B. became bulimic during her freshman year at
college. After numerous costly visits to the dentist
and emergency room, A.B. sought treatment. Her
binge/purge behaviors were successfully treated in an
inpatient center, but her compulsive exercise tenden-
cies remained. A stressful life event triggered the
524 M.M. Cartwright / Crit Care Nurs Clin N Am 16 (2004) 515 – 530
return of binge/purge behavior, a common event in
the recovering bulimic. A.B. was able to address her
stressful issues and deal with them with the help of
her psychologist.
Comorbid conditions and eating disorders
Patients with an eating disorder frequently pres-
ent with comorbid conditions that complicate the
disease and its treatment. Conditions such as IDDM,
hyperthyroidism, cystic fibrosis, and pregnancy
frequently precede the development of eating disor-
ders in vulnerable persons who possess risk factors
for eating disorder.
Insulin-dependent diabetes mellitus and eating
disorders
IDDM is a common chronic disorder that afflicts
an estimated 1 in 300 to 600 persons by the age of
20 years with actual diagnosis usually occurring
slightly before or during adolescence [63]. Several
studies have demonstrated a high incidence of eating
disorders in adolescents with IDDM and a corre-
sponding increase in severe medical complications
[64 – 66].
Diabetes management requires a tight regimen of
dietary manipulation, frequent monitoring, timed
insulin therapy, and medical follow-up. Distortions
in appetite may occur in some patients with IDDM
because they must eat in response to a timed meal
plan rather than physiologic hunger [67]. Further-
more, higher body mass indices (BMIs) have been
observed in diabetic females [67]. These factors
coupled with the other risk factors may lead some
diabetics to develop eating disorders because of body
dissatisfaction, perceived lack of control over the
disease process, and a desire to bfit inQ [68,69].
Bulimia and EDNOS are twice as common in
females with IDDM than in controls. In a recent study
of 70 adolescent girls with IDDM, 37% used un-
healthy weight-control practices such as insulin
omission, skipped meals, and bulimic behaviors such
as vomiting and laxative abuse [70]. Similarly, 15.9%
of males reported using unhealthy weight practices
although none reported insulin manipulation [70].
Bulimic and binge eating tendencies are more
common than anorexia in IDDM [69].
Insulin omission induces hyperglycemia and
glycosuria. This practice usually begins in the preteen
years and increases with age, rising to 34% in older
adolescents [68]. It is not surprising that IDDM
patients with eating disorders develop long-term
complications earlier and suffer more diabetic emer-
gencies than IDDM patients without eating disorders.
Insulin omission leads to more frequent episodes
of diabetic ketoacidotic emergencies, early-onset mi-
crovascular complications such as nephropathy and
retinopathy, and elevated HA1C levels [68]. These in-
dividuals often present to the emergency room with
significantly elevated blood glucose levels, seizures,
and renal failure [64,67,71].
This author observed a trend toward an earlier age
of renal transplantation in women who were diag-
nosed with IDDM in adolescence as compared with
men. Many of these women received both a kidney
and pancreas transplant and therefore were no longer
able to omit insulin to control their weight. As a
result, the author’s team frequently observed bulimic
behaviors in some of these patients soon after surgery.
Clinical vignette four: the blind bulimic
T.R. is a 29-year-old female renal/pancreas trans-
plant recipient evaluated by a registered dietitian and
psychiatrist. T.R. has a history of IDDM of 15 years’
duration and manages her diabetes with diet, insulin,
and exercise. She attended a camp for children with
diabetes every year between the ages of 11 and
14 years. During the past 10 years, T.R. was routinely
hospitalized for significantly elevated glucose levels
and multiple ketoacidotic events. She developed se-
vere nephropathy 4 years ago, has neuropathy, and is
legally blind. She is 50500 tall, weighs 115 pounds, and
received a kidney pancreas transplant 7 days ago.
She is recovering well but has requested a no-fat diet.
Several staff members observed T.R. exercising in her
room. T.R. was transferred to a psychiatric ward for
observation where she was interviewed by the
psychiatrist about her exercise and diet behaviors.
T.R. stated that she breduced my insulin for years to
control my weight, now I can’t do that anymore.Q Her
bulimic tendencies of insulin omission seem to have
led to some inappropriate compensatory behaviors
and restrictive dieting. T.R. was admitted to an in-
patient eating disorders treatment center.
Comments
It was noted in this hospital that the average age
of kidney transplantation is lower in women than in
men. A pattern was observed demonstrating that
several women had omitted insulin for years to
control their weight. T.R. provides an interesting
example of the deep psychologic roots of eating
 M.M. Cartwright / Crit Care Nurs Clin N Am 16 (2004) 515 – 530 525

disorders: T.R. was legally blind and yet was
concerned about becoming fat.
The vicious cycle of binging and purging
Restrictive eating may lead to binge eating.
Restrictive eating involves trying not to eat for long
periods, minimizing food intake even though hungry,
and avoiding specific foods or food groups [33].
Physiologic changes associated with dieting may alter
the body chemistry before the binge. Low blood
glucose, depletion of glycogen stores, low or inade-
quate serotonin, and psychologic deprivation may
preclude a binge. Hence, binges associated with
anorexia nervosa, bulimia nervosa, and binge eating
disorder may be caused by an underlying hormone or
neurotransmitter imbalance. Before the binge, the
anorexia nervosa purger or bulimic may feel anxious
and distressed; during the binge, there is relief and
lack of control; after the binge, disgust, depression,
and guilt prevail. These behaviors and feelings may
stem from CCK, serotonin, and endorphin imbalan-
ces (Fig. 3) [16,17,21,33].

Cortisol, neurochemical imbalance

Stress, anxiety
SSRIs
Anti anxiety drugs
Behavioral therapy Binge

Excessive Exercise Dietary Fat Dietary Carbohydrate

Endorphins CCK Serotonin

During the Binge

Lack of control
Relief

Post Binge

Neurochemical withdrawal
Depression
Guilt

Purging
Restrictive Dieting

Fig. 3. The binge/purge cycle (broken lines indicate inhibition). Neurochemical imbalances, high cortisol levels, or stress and
anxiety often precede a binge. Consumption of large amounts of calorically dense, high-fat, high-sugar foods set off a
neurochemical cascade characterized by increases in cholecystokinin (CCK), serotonin, and endorphins. Excessive exercise may
also trigger high endorphin levels. As a result of these chemical changes, the person may feel relief and temporary satiety during
the binge; however, when the chemical deluge wanes, the person will likely experience withdrawal, guilt, depression, and
anxiety. Purging of excess caloric intake by inappropriate compensatory mechanisms or restrictive dieting follows, and the
subsequent decrease in neurochemicals and rise in stress levels result in another binge. Medications such as selective serotonin
reuptake inhibitors (SSRIs) and anti anxiety drugs as well as behavior therapy may curb binge eating behaviors and excessive
exercise tendencies. Data from Refs. [3,16,17,21,33].
526 M.M. Cartwright / Crit Care Nurs Clin N Am 16 (2004) 515 – 530
Food and mood
What is consumed can affect body chemistry.
Protein and fat trigger release of CCK from the small
intestine. CCK provides a feeling of fullness or
satiety. Protein also impacts levels of dopamine, a
neurotransmitter that causes a feeling of alertness.
Dietary fat influences production of endorphins, the
body’s natural painkillers. Dietary carbohydrate, par-
ticularly simple sugars, stimulates serotonin produc-
tion, a neurotransmitter that induces calmness and
sleepiness. Hence, if one eats ice cream, a food high
in fat and simple sugar, the result is often a feeling of
calmness, relaxation, and satiety caused by the
release of serotonin, endorphins, and CCK. Many
sufferers from eating disorders have abnormal levels
of these chemicals, which may lead to binge/purge
behaviors [16,17,19 – 21]. Medications, exercise,
starvation, and vomiting can also influence produc-
tion of this neurochemical milieu (Fig. 3).
Many bulimics experience low serotonin and CCK
levels. Thus, they often have cravings for sweets and
never feel full or satisfied, even after consuming large
amounts of food. As a result, bulimia nervosa patients
binge on high-calorie foods, and the temporary rise
in serotonin leaves them feeling calm and sedated.
After the binge, purging may follow, causing a tem-
porary surge in endorphins. Once the serotonin and
endorphins wane, the binge/purge cycle begins again
(Fig. 3).
Treatment of anorexia and bulimia
Once the patient’s medical complications have
been addressed and stabilized, in-hospital treatment
aimed at treating the physical and psychologic facets
of eating disorders can begin. Assessment is the first
step to treatment. Patients with eating disorders are
notoriously unreliable informants and have secretive,
manipulative tendencies; denial of illness is common
[50,72,73]. Interviews with the patient, patient’s
family, and friends are recommended. Structured
interview tools are available and should be adminis-
tered by a qualified health care practitioner [74].
Evaluation for eating disorders includes a thorough
physical examination, psychologic evaluation, and
treatment planning.
Inpatient treatment administered at a qualified
psychiatric facility is recommended for patients who
experience rapid self-induced weight loss (to less
than 85% normal weight), acute psychiatric events,
or significant medical complications. Inpatient treat-
ment is also indicated if outpatient facilities are
not available.
Outpatient treatment is similar to inpatient treat-
ment but involves a group setting with individualized
therapy. These patients are typically medically stable.
Psychotherapy, group therapy, family therapy, cogni-
tive-behavioral therapy, and self-help are frequently
used individually or in combination in both inpatient
and outpatient facilities.
Antidepressant medications, such as selective
serotonin reuptake inhibitors (SSRIs) are often used
to treat bulimia. SSRIs may help prevent relapse in
patients who have achieved normal weight. Anti-
anxiety medications and atypical antipsychotic agents
may be beneficial to anorexics [75].
Orthorexia nervosa—a new eating disorder?
In 2002, Steven Bratman [76] recognized an
eating disorder – like behavior he calls borthorexia
nervosaQ (from borthoQ meaning bstraight, correct, or
trueQ and bnervosaQ meaning bobsessionQ) describing
individuals preoccupied with eating only bhealthy
foods.Q Orthorexia typically stems from a recent
disease diagnosis and a desire to regain control. For
example, a patient who suffers a sudden heart attack
may try to follow a completely fat-free, cholesterol-
free diet. Characteristics that separate the orthorexic
from the health-conscious person are an extreme
preoccupation with food, associating food choices
with virtue, eating only specific foods deemed
healthy or pure, judging others based on their food
choices, experiencing social isolation because of diet,
and feeling guilt or self-loathing if diet is not
followed correctly [76]. Orthorexia occasionally
overlaps with obsessive-compulsive disorder or other
psychologic conditions [76]. Although not recog-
nized as a true eating disorder and regarded as
controversial by some experts, it is nevertheless an
interesting description of a presentation that has been
observed by this author.
Clinical vignette five: the orthorexic patient
L.B. is a 53-year-old man who had a triple coro-
nary artery bypass graft 2 years ago. When L.B.,
with his wife, visits his general practitioner for a
check-up, the physician recommends a consultation
with the dietitian, because L.B. is 50900 tall and weighs
125 pounds. He has lost a significant amount of
 M.M. Cartwright / Crit Care Nurs Clin N Am 16 (2004) 515 – 530
weight during the last year. A gastrointestinal work-
up reveals no issues. L.B. states that since his
diagnosis of coronary heart disease and high cho-
lesterol, he only eats bnatural and organic foods.Q
Foods such as dairy products, sugar, and wheat are
bforbiddenQ because they are bdangerous.Q L.B.
comments on the dietitian’s lunch of Caesar salad
with chicken—bmeat stays in the bowels for 7 years.Q
L.B. proudly states that his system has bbeen
cleansed by fasting and consuming only raw foods
and unpasteurized juice.Q He reports a recent bout of
bstomach flu.Q L.B. does not work because of bstress.Q
L.B.’s wife comments that they rarely socialize or eat
out because most people bdo not understand L.B.’s
health problems.Q
Comments
L.B. probably has orthorexia nervosa. He clearly
is preoccupied with food and judges others based on
their food choices. He is socially isolated and avoids
foods he once enjoyed. His bout with the bstomach
fluQ was probably caused by consumption of unpas-
teurized juice and raw, unwashed foods. Cases like
L.B. are becoming more common. Patients diagnosed
with heart disease, cancer, and other illnesses, often
seeking a form of control, occasionally follow very
restrictive diets for a short period after diagnosis.
Orthorexic patients typically follow restrictive pat-
terns over a longer period of time and exhibit specific
personality characteristics outlined previously.
Case study: the emergent complications of an
eating disorder
P.C. is a 39-year-old woman admitted to the
emergency room after collapsing at the gym. Her
past medical history includes anorexia with self-
induced vomiting and laxative abuse of 10 years’
duration and frequent emergency room visits for
esophageal and rectal bleeding . She has a history of
amenorrhea, electrolyte imbalances, osteopenia, and
cardiac arrhythmias.
She was divorced 10 years ago. She does not
smoke. She drinks four glasses of wine daily. She
works as a personal trainer. P.C. performs 3 hours of
cardiovascular exercise each morning, followed by
2 hours of weight training in the mid-afternoon
and another hour of cardiovascular exercise in the
evening. Her food intake is limited. Her roommate
reports that P.C. weighs herself frequently. She also
weighs all of her food and beverages and compares
527
these values with weights of emesis, urine, and fecal
matter. She is known to keep a detailed log of her
exercise regimen and intake and output.
On admission, her heart rate was 66; her blood
pressure was 80/62; her respiratory rate was
24 breaths/minute. The EKG revealed prolongation
of the QT interval. Her laboratory results indicated
metabolic alkalosis: albumin, 3.2 g/dL; sodium,
129 mEq/L; potassium, 2.6 mEq/L; chlorine,
90 mEq/L; BUN, 90 mg/dL; creatinine, 6 mg/dL;
glucose, 80 mg/dL. On physical examination, she is
very thin (height: 50600, weight: 98 pounds). Her skin
is dry with yellowish discoloration and is cold and
clammy to the touch. Her hair is brittle and thinning.
Her nails are thin and discolored.
P.C. reported limited urine output over the last
24 hours and abdominal cramping. She uses over-the-
counter laxatives, herbal remedies including a tea
comprised of fennel seeds, senna, licorice root, ma
huang, and dandelion root, and occasionally ipecac.
Diagnosis revealed cardiomyopathy and multiple
renal cysts. P.C. was stabilized in the emergency
room with fluids and electrolytes and then was
transferred to the dialysis ward where hemodialysis
was started. P.C. was not compliant with her dietary
regimen and continued to induce vomiting. P.C. was
transferred to the psychiatric unit for observation
and treatment.
Comments
Although most patients with eating disorders are
adolescents or young adults, age should not be an
exclusionary factor in the diagnosis of eating
disorder. P.C. works in a field that values thinness;
her eating disorder started around the time of a
traumatic life event. She abuses bnaturalQ laxatives
such as senna and fennel seeds, diuretics such as
dandelion root and licorice root, and appetite sup-
pressants that contain ephedra such as ma huang.
Fainting spells with exertion and fractures related to
osteopenia with exercise are common. It is common
for patients with eating disorders to keep detailed logs
of structured diets, exercise regimens, and weight.
Hypokalemic nephropathy and cardiomyopathy have
been observed in bulimics and purging anorexics.
Patients like P.C. are frequently seen in the emer-
gency room for a host of medical complications
related to the eating disorder itself. Treatment takes
several months or years, and many patients never
recover completely. There is a high recidivism rate,
with eating disorder – like behaviors returning with
significant life stressors.
528 M.M. Cartwright / Crit Care Nurs Clin N Am 16 (2004) 515 – 530
Prognosis of patients with eating disorders
Early recognition and treatment of eating disor-
ders result in more successful outcomes. Most
anorexics and bulimics practice their eating disorders
for 1 to 15 years before seeking treatment [23,74,77].
Earlier age of onset and longer duration of practice
are associated with less successful treatment out-
comes. For anorexics who receive treatment, 40%
make a complete recovery, 40% make only a partial
recovery, and 20% have chronic health problems
that may have a fatal consequence. For bulimics,
50% recover completely; 35% experience a relapse
of bulimic behavior, and 15% suffer from chronic
bulimia [77]. Comprehensive treatments involving
several health care practitioners are vital to the
successful recovery of the patient with an eating
disorder [77].
Summary
Eating disorders are complex maladaptive behav-
iors that can result in significant medical problems
requiring emergent treatment. Patients with eating
disorders present an unusual challenge to the health
care provider because there are strong psychologic as
well as physiologic aspects to consider. Thorough
medical evaluation and ongoing medical manage-
ment are crucial to the care and survival of these
patients. Multiple strategies aimed at stabilizing the
patient after an emergent situation should be instituted
before treating the eating disorder itself. Appropri-
ate follow-up care that includes pharmacotherapy,
psychotherapy, and behavioral therapies is warranted.
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