Introduction
In the future, I expect to be an internal medicine physician. As an internist, I will focus mainly on the management of non-surgical conditions in adults. Internists encounter a variety of psychiatric comorbidities in their practice.
As my plans are to specialize in endocrinology and diabetes, I will encounter different psychiatric disorders that comorbid with diabetes mellitus, more so with type I diabetes mellitus.
Depression-this is the most common of the psychiatric disorders in patients suffering from type 1 diabetes mellitus. Depression is 2-3 times common in diabetics than in the general population. This is easily noticeable in patients having difficulty adapting to diabetes and who have poor glycemic control.
Bipolar disorders comorbid with diabetes especially type 2. This instance occurs as a result of obesity that is frequent in bipolar patients.
Patients with diabetes have a high risk of developing schizophrenia than in general public. Some raise can be linked to the inclination for some antipsychotics, especially the atypical-that cause glucose intolerance as well as obesity.
Eating disorders-bulimia nervosa and anorexia nervosa are the most frequent eating disorders in diabetic patients. Anorexia nervosa forms the discussion of this paper.
Eating disorders psychiatric comorbidity with Type I diabetes mellitus
There is a high prevalence of eating disorders in female adolescents suffering from Type 1 diabetes and quite common for young women in Western culture1. This instance is almost twice in their peers who are non-diabetic. Insulin therapy and dietary restrain are the two main causes of weight gain that predispose diabetic girls to develop eating disorders.
Anorexia nervosa
Anorexia nervosa is a serious, chronic and a fatal eating disorder that features a rejection to sustain least body weight acceptable. People with anorexia nervosa have a strong fear of increasing weight, distorted body image, and do not view this as a serious illness. This is very serious if it occurs in patients suffering from type 1 diabetes mellitus.
Anorexia nervosa is the most common eating disorder in patients with Type I diabetes mellitus. The condition is characterized by a distinct core psychopathology in which the patients’ body weight and shape is over-evaluated. Such individuals evaluate their self-worth by their weights and body shape. In order to achieve the desired weights the patients results to self-starvation and strict selection of their food intake.
Patients with anorexia nervosa have a sustained and determined quest for weight loss until they succeed. Patients view the resulting weight reduction as an accomplishment and not a problem. A condition termed bulimia nervosa is the direct opposite of anorexia nervosa, bulimia nervosa patients fail to achieve the desired body weight and shape due to frequent episodes of uncontrolled overeating. Such patients consider themselves as failed anorexics.
Atypical eating disorders are similar to bulimia nervosa and anorexia nervosa although they do not exactly meet the diagnostic criteria of the two. The features are mixed and patients may have excessive control on diets, over exercising, occasional uncontrolled overeating, and low to normal weights.
Anorexia nervosa is most prevalent in adolescent girls and young women and less common in males. The occurrence of anorexia nervosa is ten times more in females than in males. Anorexia nervosa is the most common form of eating disorders in young women and girls that normally starts in the mid teenage. The mortality caused by this disorder is estimated at 4% to 10% and the risk prevalence in young women is 0.5 to 1 percent 2
Risk Factors
Anorexia nervosa has low incidence in the population therefore making identification of risk factors difficult. However several risk factors have been associated with the development of the disorder. These include difficulties in eating in early age, parenting style, anxiety symptoms and perfectionist traits. Cultural factors are also considered by some scholars as a risk factor although others dismiss it completely. Genetic factors have also been considered as important risk factors in anorexia nervosa with heritability estimates ranging from 33% to 84%.
Participation in certain activities such as modeling, athletics, beauty contests, dancing and other activities that promote thinness; personality traits such as low self esteem and perfectionism; difficulty in expressing negative emotions; poor conflict resolving techniques are also important risk factors that predisposes young women to anorexia nervosa.
Health problems, symptoms and signs
Anorexia nervosa is characterized by severe restriction of food intake and over evaluation of one’s body weight and shape. This is common in women in western cultures where beauty is associated with thinness. The severe restriction to food intake leads to serious health and psychological complications that may lead to death. Life threatening medical complications of starvation includes induced hypothyroidism, oesteopenia and osteoporosis, risk of caesarean section in case of pregnancy due to abnormal birth weight, loss of weight, reduced bone density and dental damage due to vomiting. Other health complications include very low weight, rapid weight loss, pronounced oedema, severe electrolyte disturbance, hypoglycemia, and great intercurrent infectionю
Common presenting symptoms in most patients include “fatigue, dizziness, and lack of energy, sore throat, amenorrhea, gastroesophageal reflux disease, abdominal pain, cold intolerance, constipation, abdominal pain, polyuria, polydipsia and palpitations”. Patients may also have signs such as “bradycardia, orthostatic hypotension, hypothermia, dry skin, lanungo (fine body hair), enlargement of salivary glands and hypercarotenemia”. Most patients deny these symptoms although the family members may express concern about them.
Diagnosis
Use of simple screening questions can indicate whether a patient has the disorder for instance “Do you think you should be dieting?” Physical examination and laboratory investigations may also be used in diagnosis of this condition. Of a critical role in diagnosis of anorexia nervosa is the family doctor. The family physician coordinates diagnosis and treatment through multidisciplinary practice with other health professionals4.
DSM-IV diagnostic criteria
The current diagnostic criteria based on DSM-IV involve observation of four criteria. Most patients exhibit a refusal to maintain their body weights at the normal weight for their age and height. Secondly patients have great fear of becoming fat or overweight although they are underweight. The third diagnostic criterion is the observation of disturbances in how the weight or shape is experienced by the patient, denial over the low weights and over-evaluation of oneself on the basis of weight and shape. Amenorrhea i.e. the absence of at least three successive menstrual cycles is also a common diagnostic criterion in post menarchal females. In addition to physical examination and laboratory investigations, one may also employ medical history In diagnosing a patient for anorexia nervosa.
How Anorexia nervosa may impact on my medical treatment of a patient with T1DM
Diabetes is a very complex disease and affects all aspects of daily life, more so, eating behaviors. Restraining from diet and food preoccupation may have far reaching impacts on daily events of life. Unlike in common cases of diabetes mellitus, managing patients with eating disorder has significant challenges3. Diabetes management requires close monitoring of food intake because insulin intake can only be adjusted on the basis of caloric intake. Anorexic patients preclude knowing actual food intake thus making the management of the condition very difficult.. These may make my evaluation and management of the condition very complicated. Instead of following the contemporary procedure in management, first I would warn her that they should never stop taking insulin as a way of losing weight and describe to her how dangerous this is; we know that anorexics are desperate to lose weight. I will warn her about insulin overdose. I will advise the patient that she should eat something when she feel dizzy because this is life threatening condition and emphasize that dizziness from low food intake is different from insulin over. The dizziness she experience from not eating is different from dizziness she might get from an insulin over dose. The patient should differentiate between the two and keep in mind that this is life threatening. I should monitor their blood sugar level very closely and if it’s high I will assume that she is not taking insulin so as to lose weight. I will arrange to see her more frequently than other patients and watch her for any signs of ketoacidosis; also warn the patient family to watch for these signs too. In general I should get the patients family and friends to be included in the treatment because the patient might not be aware enough to treat herself.
How I will work with an anorexic patient to help with this psychiatric issue
Additional comments are necessary when managing an adolescent with type 1 diabetes mellitus4. After obtaining the historical and physical records of the patient, I will request the patient to keep a detailed log of dairy food intake and specify the exact type of food and drink and the amount that must be adhered to5. I will also emphasize on the type of insulin that the patient must take. Additionally, I will request the patient to agree to keep a blood glucose log and to bring his/her diaries, log books, and blood glucose monitor to me all the time she visits. I will provide the patient with guidance on diabetic management and lay out the actions that are required should he/she face difficulty in complying with the ground rules or the amount of food consumed or should the body weight continue deteriorating.
Upon reaching an agreement, I will request the patient to see me at the clinic once a week. On each visit, I will review the diary contents and give him/her the feedback concerning the amount of calories consumed and the appropriateness of the insulin regimen. Should I notice a positive change on energy intake, I will complement the patient and urge him or her to go ahead and list other foods she/he finds appealing to increase her caloric intake. I will then adjust insulin doses so as to maintain blood glucose levels in the targeted range. If I notice that the patient’s weight is now normal, I will not continue with this action but should I notice that the weight keeps deteriorating, I will put the steps outlined on the ground rules into effect.
Additional treatment modalities expected from psychiatrists in the treatment of this disorder
Cognitive behavioral psychotherapy
The major premise on which cognitive behavior therapy is based is the fact that the two salient features of anorexia nervosa i.e. excessive food restriction and avoidance are habit patterns that are entrenched irrespective if circumstances that initiated them. Cognitive psychotherapy involves three therapeutic phases.
In the first phase of this therapy, the motivation of the patient to engage in treatment is first evaluated and her uncertainty to give up the disorder is addressed. The second phase of the therapy involves educating the patient on cognitive behavior therapy skills that would help her give up any illogical and dysfunctional thoughts particularly regarding her body weight and shape. The therapist may give the patient some psycho-educational materials to read. In the third phase of cognitive behavior psychotherapy, the patient is prepared for termination. This also involves giving the patient information on relapse and recovery and teaching strategies to reduce risk of relapse.
Interpersonal psychotherapy
In the first phase of interpersonal psychotherapy, a history of the patient’s life events is obtained, interpersonal relationships and eating problems are also obtained and any relationships between these aspects is noted. The therapist also tries to establish the problems within the four main problematic psychotherapy areas. The second phase of psychotherapy focuses on the identified problem areas. An assessment of the symptoms is important in this phase because it helps to identify links between the symptoms and interpersonal issues. The presenting symptoms of eating disorder in the patient are used to help in facilitating the therapist work well on the interpersonal problem. In the final phase of interpersonal psychotherapy, termination is initiated so as to help the patient cope with the disorder.
Family structure and therapy
Family based approaches to treatment of anorexia nervosa especially for adolescents are more effective that individual approaches. Family therapy is most effective in treatment of anorexia nervosa since it is a socially based problem. A family therapist is usually involved in doing the family restructuring. Family restructuring helps in controlling the symptomatology and therefore assist in the patient’s recovery.
Discussion of my personal views
The use of insulin glargine (Lantus) combined with rapid acting insulin analogs; such as insulin lispro and insulin as part are among the best ways of meeting a patients insulin requirements. If the patient agrees to food intake, she should be provided with a dose of rapid acting insulin analog before and after meals6. However, if a patient’s food intake is unacceptable, a dose of rapid acting analog is necessary to cover a minimum desired food intake. Complete failure of food intake should be tackled with nasogastric feeding.
Conclusion
I really think that psychiatry is a very important part of medicine. Every physician should have a good knowledge of psychiatry including all different psychiatric conditions he/she might encounter. This was a good example of why as an endocrinologist I should be aware of psychiatry to maximize the quality of treatment to my patient. I also think that I should be in touch with a psychiatrist and consider referring them because this will make my treatment as endocrinologist more effective and beneficial.
References
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Jacobs MJ, Roesch S, Wonderling SA, Croshy RT. et al. Anorexia nervosa trios: behavioral profiles of individuals with anorexia nervosa and their parents. Psychological Medicine. 2009;39:(3):451-461.
Balhara YP, Sagar R. Correlates of anxiety and depression among patients with type 2 diabetes mellitus. Indian Journal of Endocrinology and Metabolism 2011;15(1):50-4
Kent D, Haas L, Lin E, Thorpe CT, Boren SA, and Fisher J. Healthy coping: issues and implications in diabetes education and care. Population Health Management. 2010;13(5): 227-33.
Prisciandaro JJ, Gebregziabher M, Grubaugh AL, Gilbert GE, Echols C, Egede LE. Impact of psychiatric comorbidity on mortality in veterans with type 2 diabetes. Diabetes Technology and Therapeutics. 2011;13(1):73-78
Walsh JM, Wheat ME, Freud K. Detection, evaluation, and treatment of eating disorders the role of the primary care physician. Journal of General Internal Medicine. 2000; 15(8):577-90
