Anorexia

Michele is a 15-year-old brought in by her mother, to see if her medical condition was dangerous. Michelle wanted to go to a Soccer camp. Yet her mother was unsure if Michele was healthy enough to be allowed to go to the camp. Michelle is required by her family doctor to gain 3 lbs. in the next three weeks in order to be allowed to go to the soccer camp. Her mother is concerned, and she may die due to poor medical care.

1. Michelle will probably be in need of treatment for at least 2 years. She will need a team that includes various specialists. The frequency of meetings will depend upon many factors unique to each child.
   
   *She will need a family doctor or internist familiar with eating disorders.
   
   *She will need a child or adolescent psychiatrist with interest in eating disorders that does both therapy and medication. If they are only doing medication, Michelle will need a separate therapist with 5 years experience in eating disorders.
   
   *Michelle will also need a nutritionist. Many are quite familiar with anorexia. I would ask if they have had at least 20 anorexia clients for ongoing long-term care.
   
   *Parents also often benefit from a coach. Therapists differ on whether your child's therapist can also be your coach.
2. What are more serious flags to increase treatment? If a menstruating youth stops menstruating, has basic blood tests in the abnormal range, is 20% below her recommended weight, or is suicidal or cutting then having a full treatment team is mandated. If the pace of weight gain is minimal, and certainly if the youth is 30 % below their expected weight, they should be hospitalized. Generally, while anorexic patients can learn some tricks from other patients, the outcome from hospitalizations is usually good.
3. Some medical testing shows a youth needs very prompt medical care. These include an abnormal potassium blood level or an abnormal ECG. The ECG is a routine and painless heart test, which measures the rhythm and function of the heart. A physical exam may also be seriously abnormal. One or more of these types of tests may show a youth requires a brief medical hospitalization, a residential eating disorder hospitalization or a combination of both. Many youth need prolonged residential care to survive. Some controversy exists as to the death rate of anorexia. Yet for the parent of a dead child, there is no interest in percentages.
4. Typically, the child should consider food as the treatment of choice. The starved brain can sometimes increase "delusions" about the "badness of food" and the "fatness" of a skinny patient. Surprisingly, it seems that nutritional deprivation does not always increase a longing for food, but increases false beliefs that undermine eating. This is very dangerous and serious.
5. Unlike most youth, exercise should be very minimal. Particularly, sports teams and running require that the patient meet certain safe weight goals. If they need to be 105 pounds according to the internist, to join the field hockey team, they will not join if they are 98 pounds. Often, there is some denial about these conditions. I suggest the practitioner consider putting them in writing. A doctor should never fudge the truth and medically clear a youth for any sport if they are too thin to be safe. Never put pressure on them to compromise their best judgment, unless you want to attend your child's funeral.
6. Generally, everyone involved should be caring, supportive and firm.
7. Eating disordered youth think in extremes of all kinds. They think doctors, parents, or nutritionists are good or bad, caring or thoughtless. Arrogant therapists can be deceived into thinking past therapists were incompetent, when in fact the patient is seducing the therapist into thinking that way. Next year they will be the ones described in negative terms. All team members need to have good and easy ways to communicate concerns. Assume the patient will try to split and divide team members.
8. If you feel hopeless, you are being made to feel the internal world of the child—they are deeply frustrated and hopeless. They act and interact with you so that you will taste the feelings they have. I doubt much of this is something they notice. But understanding it can help you.
9. The clarity of medication use in anorexia is pitiful. Starting doses should be very low for the first days since some of these patients are very sensitive to medications, perhaps because of their brain chemistry sensitivity or reduced liver clearance ability. Do not expect propound benefits as in some disorders.
   
   I am currently tentatively looking at possible medication options to increase weight. (Each has had years of use in fragile populations).
   
   Specific options:
   
   
   • *Remeron starting at 1/4th of the 15 mg orange flavored disintegrating pill. It is not scored to make an easy 1/4th since generally this low dose is not necessary.
   • *Depokote Sprinkles 1/4th of the smallest size 125 mg capsule. The 1/4th will only be a crude estimate since dosing is made for larger mania and seizure doses.
   • *Paxil has the highest weight gain of the most commonly used serotonin antidepressants. Consider starting with the liquid form which is 10 mg per teaspoon (5 ml's) and has an orange flavor. Use only 1 ml or 2 mg to start on the first day. The FDA has recently said not to use in youth under 18. I am unaware of magical body changes that happen on your 18th birthday. The politics and issues related to this medication are not worthy of time.
   After this initial tiny dose, the physician can always raise the dose quickly if necessary. I am unwilling to be led around by the nose by pharmaceutical company dosing directions, that are untried in fragile and vigilant anorexia patients. With the first sense of a side effect, they will want to bag the medication and you will have another battle on your hands.
   
   Also, these medications at lower doses will increase weight and/or appetite slowly so the youth will not have the sense they are suddenly losing profound self-control, a common issue in anorexia.
   
   Since medication treatment will need to be variable, just be sure the prescribing doctor is a specialist is child pharmacology and has read up on medications for anorexia. If you are unsure, go to the Internet and use the search word "Pubmed." Click on the Pubmed main option so you go to the massive database of millions of articles. In the search bar that appears on the Pubmed home page, put in "anorexia medication psychiatry."
   
   Print off and mail the resulting information to the prescribing physician. Unless they are academic psychopharmacologists, they probably have not done such a search in the recent months or years. This insures your child is getting the best options that are up to date. Since it is unlikely any drug company is going to seek FDA approval for a drug to treat anorexia. Therefore, your physician will have to depend on reflection on anorexia and the mechanisms of medications to offer a reasonable suggestion. Some of the medications with the most use and publications, are older tricyclic antidepressants which add some weight, but also might add slightly to the risk of a heart fatality.
10. One leading residential option I visited regularly for a month, many years ago, was the Renfrew Center at 800 Renfrew. They now have at least two centers.

James L. Schaller, MD, MAR
Naples, FL