Patients with advanced abiotrophy need improvement in their physical condition because they are facing a life-threatening situation.7 Early physical treatment is also important because advanced abiotrophy or an electrolyte imbalance can cause permanent physical disorder. After seeing the development of renal failure and necessity for artificial dialysis in one patient, or the development of anaplastic anemia in another (both the result of long-term advanced abiotrophy), we strongly feel that severely anorectic patients should always undergo inpatient treatment in order to improve their physical condition.8
Although 70% SBW is generally the guideline used for inpatient treatment among anorectic patients, most would not seek treatment at that stage. In most cases, both the families and patients themselves do not visit psychiatric facilities until they realize the seriousness of the situation, when the patient's weight has come close to 60% SBW. At such a low weight, death is already imminent. This conclusion was reached based on the following experiences.
A patient who visited us with a weight of 76% SBW had been treated as an outpatient. Soon after, she fainted in the bathroom and fractured a bone in her face. Her weight was 57% SBW at that time. Another patient who came for treatment with a weight of 57% SBW and reserved a hospital bed, was a few weeks later admitted to the intensive care unit in a hypoglycemic coma because her mother had cancelled her reservation. Even though she pulled through, she was left with severe brain damage. There was another patient who attended as an outpatient because her blood screening and vital signs were all normal. Her weight at the first visit was 64% SBW. When admitted with 59% SBW only 1 month later, she already had advanced liver dysfunction with a serum bilirubin level of 5.0 mg/dL.
Among chronic-stage eating disorder patients, there are those with stable weight at approximately or less than 60% SBW. However, many acute-stage patients rapidly worsen. Such cases led us to conclude that patients weighing close to 60% SBW in acute stage should be admitted immediately.
Intravenous hyperalimentation and duration of inpatient treatment
Particularly for patients who enter the acute stage soon after onset, a CV is inserted into the patient's middle cardiac vein in order to manage the general state of severe anorexia. Although patients may be fed very effectively through IVH, there are reported risks.9
First, the insertion of a CV and supply of the nutrients, water, and electrolytes is in itself considered a high risk by some. In terms of insert-related risks, it could possibly cause a pneumothorax or a centesis artery. At Nagoya Daini Red Cross Hospital only experienced physicians perform this procedure, and no serious problems have been reported thus far. Although there is also concern about congestive heart failure due to oversupply of water and the refeeding syndrome due to sudden resupply of nutrients, such can be prevented by increasing the amount of IVH, by monitoring very carefully the patient's weight change and electrolyte levels. Although IVH is used for many patients in facilities that treat a large number of serious cases, there have been no reports of serious mishaps or complications from IVH due to recent advances in treatment techniques
Second, there is the possibility of patients themselves manipulating the CV to change the IVH drip infusion or discarding the intravenous solution from a three-way tap. This could lead to an aeroembolism or infection. Thus, we always emphasize the risk of these behaviors, both in conversation and in a written statement upon admission. Although our procedure has been used for more than 100 IVH patients, we have never encountered any serious accidents. However, among patients needing repeated hospitalizations are some who discard the intravenous solution or pull out the cannula on their own. In such cases, IVH treatment should be discontinued, although these cases did not occur in the present study.
The advantages of IVH are as follows. First, it can shorten the duration of inpatient treatment. Although the patient must gain more than 10 kg in weight, it is extremely difficult to achieve 12 560 kJ (3000 kcal)/day via oral or nosogastric intake alone. However, nearly 16 740 kJ (4000 kcal)/day is feasible with both oral intake and IVH. The majority of these patients are still in school, and a long-term hospitalization might mean having to repeat an academic year. Inpatient treatment with IVH enables us to tell patients that they can leave leave the hospital after 2 months, if all goes well, when trying to persuade them to accept inpatient treatment.
One should never overlook the psychotherapeutic significance attached to IVH. Many patients may resist dietary intake or alimentation by nasogastric tube, but they show virtually no such resistance to having a catheter inserted into their main vein. They also do not seem to mind a high-calorie fluid intake through a catheter.2,10 The patient feels comfortable with the idea that instead of ‘putting on weight’, she is receiving the right treatment. The IVH stand with the large drip-infusion bag hanging on it offers reassuring proof that they are indeed ill, a genuine patient. Moreover, the patients with an eating disorder often complain ’I don’t know how much I should be eating’ or ’If I eat too much my stomach really will get big’. However, in this type of treatment, the meals are geared to the patient's age so this feeling can be avoided.
Out of the 51 patients who were reviewed for the present study, 46 completed their inpatient treatment with a mean hospital stay of approximately 64 days. Patients with the restricting type and the binge eating/purging type had a similar course of treatment and were discharged after a mean of 2 months. We originally suspected that the patients with the binge eating/purging type might need a longer course of treatment because of their behavioral problems, but this was incorrect. According to reports, the mean hospital stay of patients at special facilities for eating disorders is also a few months.11 In contrast, in the study by Denda et al. the mean hospital stay of 12 patients treated with IVH was approximately 5 months.2 It is not easy to compare studies because each facility has different criteria for judging the need for inpatient treatment, the type of treatment regimen, and standard for discharge. However, it was significant that the bodyweight of the present anorectic patients could be increased up to 80% SBW in 2 months, which reflects a certain measure of success in a short hospitalization.
Outpatient treatment after discharge
In treatment of eating disorders on an outpatient basis, it is critical to establish a patient–therapist relationship at the beginning of treatment.12 One can introduce them to psychotherapy rather smoothly by focusing on their resistance to treatment and their anxiety about a cure as their physical condition improves. This might determine whether treatment can continue. In the present cases, almost all of the patients continued outpatient treatment after discharge. This was true of patients whether their initial prognosis was poor or good.
For patients with more than 65% SBW upon their first visit, we normally chose outpatient treatment. We also reviewed patients who came to Nagoya Daini Red Cross Hospital during the same period when the subjects of the present study were admitted. Twenty anorectic patients who consulted the authors for the first time were not admitted. Nine of the 20 continued their outpatient treatment for a mean 22.3 months. However, the remaining 11 patients dropped out after one or two visits. We interpreted this to mean that they might be less severely ill patients who came to the hospital to try out the treatment. The more severe patients who required admission were less likely to drop out from the overall treatment.
For the evaluation standard of anorexia nervosa, even though the Global Clinical Score by Garfinkel et al.13 or the Morgan–Russell Outcome Assessment Schedule14 could be used, these evaluation systems tend to be too detail-oriented. Moreover, the Morgan–Russell outcome criteria (MRC) are very useful for assessing recovery but do not take into account social adjustment.15 Many patients with anorexia nervosa manage to attend school and hold a job despite their severe emaciation. In contrast, there are many patients who neither go to school nor have a job, yet are well enough to resume a normal life. This makes it difficult to determine their physical and social outcome on a single scale.
Strober et al. conducted a prospective study on 93 cases of anorexia nervosa.16 Using the MRC to assess recovery, they indicated that partial and full recovery increased with the years after discharge, reaching a plateau of 87% and 73%, respectively, after 10 years. There was not much change thereafter. From our recovery survey, we found that 20.5% of the present patients had reached normal bodyweight, reflecting the great difficulty associated with weight normalization. Moreover, only 22.7% of them had resumed menstruation. Weight normalization and resumption of menstruation reportedly increased rapidly between the fourth and fifth year. This should be examined further over a longer time. The mean bodyweight of their patients was 69.9%, against the much lower 58.6% of the present patients at the time of hospitalization. A straightforward comparison is not possible. There thus appears to be a need for ongoing recovery surveys.
Tanaka et al. conducted a follow-up study (mean 8.3 years) on 61 anorexia nervosa patients.17 Using the MRC, 31 cases had a good outcome, eight had an intermediate outcome, 15 had a poor outcome, and seven died. Factors in their poor prognosis included late onset (>20 years of age), low minimum weight, and impulsive behavior. Because their mean weight at the time of hospitalization was around 65% of SBW, their overall body condition was better than that of the present patients. Despite the difficulty of comparison, they obtained the same results: the higher the age of onset, the less favorable the prognosis.
Three among 51 patients died during the present study. Although there are few reports on short-term mortality rates, Tanaka et al. reported two deaths among 23 patients between 1 and 3 years after discharge.18 Although simple comparison is inappropriate due to the differences in length of hospitalization and treatment, we consider the mortality rate in the present study to be small. In a search of the literature we could find no reports of recovery surveys of patients with an SBW of <60%.
Patients with serious anorexia nervosa whose weight is less than 60% SBW at initial treatment face life-threatening risk and should be treated by IVH to supply nutrients and manage their general condition. This method addresses the psychological as well as the physical needs of the patient, and with careful administration compares favorably with other reports even in regard to mortality rate.