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Ask the Mental Health Expert Archives 2001-2004

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Wife with Eating Disorder

Q. My wife is anorexic bulimic and has been since she was 15 years old. She is now 30 years old and we have 2 kids. Her front 2 teeth have major enamel missing from them. They are so bad that it has been capped by a dentist. Because she is not willing to get help for her disorder and I feel like I am constantly walking on egg shells, I have chosen to leave this damaging situation for the betterment of our children.

When someone has been anorexic bulimic for 15 years, can they be treated on an outpatient basis or is some type of inpatient care usually required to overcome such long-term damage?

A. The general answer to your question is that the long time interval between onset of illness and beginning of treatment seems to predict a poor outcome in some patients with eating disorders (Hsu et al, 1979;Steinhausen at al, 1991). However, there are many individual variables that come into play, and I wouldn't want to make any confident predictions about your wife.

First off, it's not clear from your description what eating disorder she has. There are two main eating disorders, anorexia nervosa (AN) and bulimia nervosa (BN). Each has distinct but overlapping features and clinical outcomes. Basically, AN involves a severely disturbed body image (the near-delusional belief that one is too thin, even when one may be of normal or even excessive weight) and either (1) a pattern of severely restricted food intake; or (2) binge-eating/purging (self-induced vomiting).

AN patients, by definition, have lost substantial weight and are at least 15% below normal weight. BN patients do not share the severe disturbance in body image, but they do show dissatisfaction with their body image. They engage in binge-eating, followed by some type of compensatory behavior; e.g., laxative use, self-induced vomiting, intense exercise, or fasting.

Sometimes, though, it is hard to distinguish AN from BN, which is perhaps why you refer to anorexic bulimic symptoms. Poor prognostic factors in AN include older age at onset; a binge-purge pattern; and extended length of time the patient is ill before referral for treatment. So, it sounds like your wife would have at least the last two risk factors. Prognostic factors in BN are not as clear, but poor impulse control does correlate with poor outcome.

Most likely, outpatient therapy would be attempted first in a case such as your wife's, unless she were at immediate risk of serious medical problems (which may be the case). If that were not successful, an inpatient admission would probably be advised.

November 2002

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