by Harvey Widroe, M.D.
American Reporter Correspondent
July 20, 2007
Eat or Die, Part VI
THE PATIENT SURVIVES
ORINDA, Calif. -- Debbie, a 17-year-old now down to 86 pounds and ever closer to her secret goal of 81 pounds, slowly awoke in her bed on a hospital intensive care unit. She was so groggy from her drug overdose that the only thing she noticed was the painful burning sensation in her nose.
She then discovered that she couldn't move her hands to rub the unpleasant sensation away. Debbie had survived her suicide attempt and finally figured out that padded leather restraints secured her wrists and ankles to the sides of the bed. The burning sensation came from a tube that had been inserted through her nose down into her stomach.
The tube had been used initially to pump out whatever pill fragments in Debbie's stomach had not been absorbed before she reached the hospital. After monitoring her for awhile the medical doctor decided that because her nutritional condition was so precarious, the nasogastric tube would be used for feeding Debbie's malnourished body.
Twice a day she was to receive several glasses of a milkshake like substance loaded with everything anyone would need to stay alive. What intravenous fluids she received were great for dehydration or restoring electrolyte balance, but they hardly did anything for nutrition. Prior to the restraints being removed Debbie was cautioned not to pull out the tube, or it would have to be reinserted.
When she was a few steps removed from death's door, Debbie had been transferred from the intensive care unit to the psychiatric ward of the hospital. At that point medical responsibility for her care passed from an internist to a psychiatrist; it was her job to prescribe Debbie's medication, order her diet, and write other orders regarding day to day restrictions or activities. Her efforts at helping Debbie were coordinated with those of an eating disorder psychotherapist and the hospital nutritionist.
The psychiatrist's decision to continue with twice daily nasogastric tube feedings was not made easily. However, a review of Debbie's physical downhill course left no other reasonable course of action. To keep her alive required drastic action, and a feeding tube is often the last resort.
Despite having been cautioned to the contrary, Debbie promptly pulled out her nasal tube. She couldn't believe that at the next meal time four nursing staff members held her down to replace her restraints and reinsert the feeding tube. Debbie learned fast. From then on she cooperated with the tube feedings.
Her psychiatrist tried to explain what was going to happen and why it was all necessary. Most of it Debbie had already heard, but always in the form of vague threats by her primary care doctor or even her parents. The tube feedings were to continue until Debbie started gaining weight, real weight this time, and not weight from loading up with water. Lab work was to be done daily until Debbie was, at least from a medical point of view, safely out of the woods.
Debbie hated the psychiatrist even before she met her. She identified the psychiatrist as the one responsible for the tube feedings, and for keeping her here in the hospital with "a bunch of crazy people." The psychiatrist was the villain who was prescribing medication that she couldn't spit out because it was all going through the tube straight into her stomach.
The psychiatrist saw Debbie daily while she was in the psychiatric hospital, the same as any other physician sees patients hospitalized for medical conditions. She seemed to Debbie to ask the same questions during each visit, a way of monitoring her physical and emotional conditions.
Medications prescribed by psychiatrists can help patients who suffer from anorexia or bulimia. Some drugs like Remeron or Zyprexa help restore and increase appetite. Others, especially antidepressant medications of the SSRI class such as Zoloft, Paxil, Luvox and Celexa, actually reduce the compulsion to stuff and vomit.
Patients describe the result as a newfound ability to obsess less about eating and to have a reduced internal need to purge. These same antidepressant medications often help eating disorder patients recover from severe depression. Mood stabilizing medications such as Risperdal or Seroquel can stop the eating disorder victim's emotional roller coaster and actually erase suicidal thinking and feelings of desperation and despair.
Debbie slowly befriended the psychiatrist. She came to realize that the doctor was trying to help her, even though at times she was very much opposed to what she was being advised or even ordered to do.
Over a period or weeks Debbie began to feel physically stronger and more hopeful. After the first week of hospital care she no longer required tube feedings. She began to drink the same liquid stuff that had been poured through the tube. She was observed closely for the first hour after each meal. But as closely as she was watched, at times, if she got a chance, she still was able to vomit. Nonetheless the urge somehow had seemed to weaken. Sometimes, although she had the opportunity, she didn't even think about it.
When she left the hospital some six weeks after admission, she weighed 96 pounds, an increase of ten pounds. Despite recurring feelings of anxiety about eating, she was eating solid foods with milk shake supplements. She thought, and others agreed, that some of her weight gain had begun to translate from stomach fat into muscle.
Her treatment plan included twice weekly visits to her therapist, a weekly out-patient eating disorders group where she met others with the same affliction, meetings with her nutritionist, and even appointments with her psychiatrist. Visits to her primary care doctor were now scheduled monthly. On an "as needed" basis she and her parents met with her therapist, her psychiatrist or her family doctor.
Debbie went home to live with her parents. Now that she felt brighter and knew that she was going to live, she began to think about her future. She was happy that she had a future, and she looked back on her depression and suicide attempt as a kind of ugly nightmare. She wanted to forget her hospital stay, but for now she could not.
In the hospital, she had learned a good deal about her eating disorder and its management. Her therapist kept her thinking about how to deal with obsessive thinking about eating, how to fight the "urge to purge," and how to deal with the images of a distorted body she still saw in the mirror from time to time. She didn't like taking medication, but she realized that some of the medication helped her to feel better. She reluctantly continued with the medication almost as prescribed.
While some eating disorder victims do not survive, the majority improve with treatment; hopefully long before they require the heroic measures called for to save Debbie from death.
Harvey Widroe, a longtime practicing psychiatrist, is the author of the recently published, "The Smart Dieter's Cheating Guide: Eat and Watch Pounds Melt Away," with Ron Kenner (Outskirts Press 2007).