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Outside the “Diagnostic Box”: A Case of Bulimia and Obsessive–Compulsive Disorder
Shiva Barton, ND, LAc
Abstract One of the many challenges of being a primary care physician—and a naturopathic primary care physician— is an inherent directive to consider every patient as a new and unique, highly individualized and complex case. We do not turn to diagnostic manuals as a first order of business but rather spend a significant amount of time talking with the patient, conducting a physical exam, and requesting any laboratory or others tests we may feel are relevant to the case. The true “art” (or perhaps “discipline”) of diagnosis lies not only in undertaking these steps but also in not allowing our clinical considerations to be constrained by “popular” thought or practice. A 32-year-old woman came for help with an eating disorder previously diagnosed by other clinicians. She described a daily cycle of vomiting after evening meals with constant underlying anxiety that heightened as evening hours (and thus the evening meal) approached. Shiva Barton, ND, LAc, is in private practice at Winchester Natural Health Associates located in Winchester, Massachusetts. Corresponding author: Shiva Barton, ND, LAc E-mail address: firstname.lastname@example.org
The woman was below average weight, with some alopecia. She had consulted with several physicians over her 18-year course with this condition but without apparent success. She did not reveal appreciable physical or psychological trauma or challenges to body image and self-image. These are standard psychological approaches to addressing bulimia and eating disorders, and clinicians often focus on body image, social pressure, or on the act of vomiting. She also didn’t reveal any other features consistent with a psychological origin to her condition. However, I approach these cases in a different way. My clinical experience and research have shown me that conditions such as hers are an autoimmune disorder affecting the central nervous system. My focus in this case was to determine the biological cause of the woman’s bulimia and determine if it could be eradicated.
ne of the many challenges of being a primary care physician—and a naturopathic primary care physician—is an inherent directive to consider every patient as a new and unique, highly individualized and complex case. We do not turn to diagnostic manuals as a first order of business but rather spend a significant amount of time talking with the patient, conducting a physical exam, and requesting any laboratory or others tests we may feel are relevant to the case. The true “art” (or perhaps “discipline”) of diagnosis lies not only in undertaking these steps but also in not allowing our clinical considerations to be constrained by “popular” thought or practice. So, on that
day when a 32-year-old woman entered my office to seek help for what she described as bulimia, I did not rush to my list of local contacts for psychological or psychiatric referral. This young woman, I shall refer to her as “M,” came for help with an eating disorder previously diagnosed by other clinicians. She was below average weight, with some alopecia. She had consulted with several physicians over her 18-year course with this condition but without apparent success. M described a daily cycle of vomiting after evening meals with constant underlying anxiety that heightened as evening hours (and thus the evening meal) approached. Six years ago, she took herself to the local emergency room due to sharp pain in her midabdominal area. She was released without treatment or diagnosis. Recently, the sharp pain had returned. As we discussed her health and social history, M revealed she began smoking at age 13. At age 16, her mother was diagnosed with breast cancer and M dropped out of high school in order to take care of her mother. Following her mother’s recovery, M completed high school and attended college. M later received a full scholarship
Barton—Bulimia and OCD
Integrative Medicine • Vol. 11, No. 6 • December 2012
she was not currently undertaking exercise or other specific action to address it. I believed M’s bulimia and anxiety might be a hyperimmune response triggered either by food sensitivity and/or by abnormal bacteria that had populated her digestive tract due to the early course of antibiotics. She still maintained an interest in food but vomited every evening meal after consumption. physical examination revealed M had swollen lymph glands in her neck at the time of her visit. social pressure. Diagnoses for these children may range from Attention Deficit Hyperactivity Disorder (ADHD) to autism. such as streptococcus. Tolle Causam—Can Bulimia Be an Outcome of PANDAs? After she related her medical and social histories.com. 11. or on the act of vomiting. I think everyone who takes antibiotics also Barton—Bulimia and OCD Integrative Medicine • Vol. forearm. please visit copyright. She quit smoking and has taken intermittent yoga classes in an effort to maintain her physical endurance and to address feelings of anxiety. Aside from a concussion received at age 8. so parents and clinicians sometimes do not notice any connection between the two events. visit imjournal. and the function of healthy flora in maintaining immune and digestive health is now well documented. To share or copy this article. severe anxiety. although she was aware of the osteopenia.4. I began to consider what effects these strong antibiotics may have had on M’s digestion and immune health. I approach these cases in a different way. including emotional dysregulation. such as depression and panic attacks. In addition to weight loss and alopecia. M had not experienced any bone fractures or breaks and. M is currently employed at a local retail store. No. and clinicians often focus on body image. Use ISSN#1543953X. and tics. Since the digestive tract is the largest immune organ in the body. Pediatric Autoimmune Neuropsychiatric Disorder Associated with streptococcal infection (PANDAS) is a condition identified in the 1990s by researchers at the National Institute of Mental Health2 who noticed there were certain groups of children who developed a relatively rapid onset of obsessive–compulsive disorder (OCD) and other anxietyrelated conditions after having a streptococcal infection.” she reported to me. in which molecular mimicry via the bacterium or virus triggers an immune cell onslaught against the central nervous system. and generalized anxiety disorder. she has not had the patience or ability to paint for several years. about 1 year after taking multiple courses of antibiotics for treatment of bronchitis. for example. “This problem consumes my entire life. M had never received psychological or psychotherapeutic assistance regarding anxiety or bulimia. Although the literature currently reports this condition only in children. As a young adolescent. she didn’t reveal any other features consistent with a psychological origin to her condition. I decided to look further into the cause of M’s condition. 6 • December 2012 23 . or to viruses. she has two sisters and recently broke off a relationship with her boyfriend. I believe it also occurs in adults and can include additional symptoms. In addition to her mother. hyperactivity. as an adolescent. (As a caveat. She entered one and then the other but was unable to continue either program due to problems associated with the eating disorder. -2. PANDAS is a subgroup of a larger set of conditions. After talking at length with M. Although dealing with her mother’s illness certainly was a difficult and emotionally stressful experience. developmental regression. I remarked upon the patient’s statement that she had taken several courses of strong antibiotics. Current research shows that a majority of bronchitis cases result from viral infection1. Although M is an artist. Children in whom this has occurred may present with a variety of symptoms. for treatment of bronchitis. she frequently was prescribed antibiotics to treat the bronchitis she developed as a consequence of smoking. These are standard psychological approaches to addressing bulimia and eating disorders.7. the remainder of M’s physical and social histories was unremarkable. Onset of symptoms may occur within weeks to months (or longer) of the infective episode. Within the naturopathic principle of tolle causam (treat the underlying cause). In every case. Although bulimia and other disorders associated with anxiety often are relegated to mainly psychological treatment with some adjunct pharmacological therapies (such as SSRIs).2). such as Varicella zoster. M describes herself as being “very cautious” about taking any medication. My clinical experience and research have shown me that conditions such as M’s are an autoimmune disorder affecting the central nervous system. she felt the medications were not helpful and discontinued them within a few weeks or months. I approach these conditions differently. She once consulted a homeopathic doctor but did not take the advised homeopathic remedy. In general. However. She reported a decreased sense of taste and reported she “was losing taste” for food. total spine. M’s history revealed. My focus in this case was to determine the biological cause of M’s bulimia and to determine if it could be eradicated. now known as PITANDS (Pediatric Infection-Triggered Autoimmune Neuropsychiatric Disorders). among others. separation anxiety. this was unknown several years ago and antibiotics were routinely prescribed for treatment.com to a Master’s degree program in the fine arts at two wellknown local universities. -0. M did not reveal any other physical or psychological trauma or challenges to body image and self-image.This article is protected by copyright. but she reported no pain from this. supplement. a streptococcal infection. A dual-energy x-ray absorptiometry study in 2009 also revealed declining bone mineral density (t scores: femoral neck. Having consulted with numerous clinicians throughout the last 18 years. M had taken a variety of medications. -2. To subscribe. when she was struck by a sailboat mast. however. that her difficulties with bulimia began at age 14. or botanical. Both groups include conditions that are an autoimmune response to bacteria.
I gently reminded her that the bulimia was not a defect in her willpower or character. because the bacteria can’t metabolize the carbohydrate in this alcohol sugar. She decided to take the 5HTP and the homeopathic but did not report if she felt better. M’s stool culture revealed a normal population of beneficial bacteria. Yet. they often don’t remember how they felt the first few days after taking the homeopathic remedy. No. as well as overgrowth of commensal bacteria normally found in smaller amounts in the GI tract. and reporting she was “doing ok. I have found that a homeopathic remedy will have a significant positive effect within 1 to 2 days. 11. in the morning. Yet. 25 mg per day. Bacteria are less likely to become resistant to treatment when two agents are used. (2) Goldenseal. This is beneficial against streptococcus. and she may require this type of assistance until the dysregulating influence was removed and her body was able to readjust to more optimal conditions. I thus refer patients to medical doctors licensed to obtain these tests. abnormal PAP smear): Refer to other medical doctors. M continued to report to me via e-mail. take a recommended probiotic (containing 25 billion organisms) twice daily for 3 weeks.This article is protected by copyright. The bacteria consequently absorb water and eventually explode. Docere: Research PANDAS. Throughout the next month. as well as yeast and parasites. M remained cautious about taking supplements and did not always follow the recommended treatment plan. and no yeast overgrowth.com should take a probiotic to repopulate the digestive tract with beneficial bacteria. • To treat the Blastocystis hominis infection: Grapefruit seed extract. in advance of receiving the complete laboratory report: Diet: Increase protein intake at breakfast and lunch. M’s etiology seem clear to me. Supplements. if it is the correct remedy. as advised. preferring to take only one supplement at a time. Because I practice in a state with restricted licensing for naturopathic doctors.com. 1 tsp twice daily. I requested a follow-up visit and recommended a revised treatment plan for M: Diet: Continue increased protein intake. As a homeopathic practitioner. 500 mg twice daily (or berberine 200 mg twice daily. Throughout the next 2 weeks. When M confided that she wanted to feel well without taking any supplements. Report: E-mail me every few days to let me know how you are feeling. increasing to 50 mg two times per day for 10 days (if the patient experiences no side effects). •• To enhance mental and emotional well-being: homeopathic remedy. However. A few days after beginning this treatment plan.) I generally use more than one agent to treat an infectious bacterium in order to decrease the likelihood any strains will survive.” When the laboratory results of the stool culture were returned. The test also measures dysbiotics (abnormal flora).4 • To replenish normal GI flora: After completing the above treatment plan. Supplements: •• To increase serotonin: 5-Hydroxy-tryptophan (5HTP): 50 mg per day for 4 days. although she stopped postdinner vomiting when she began taking the 5HTP. except a multivitamin. telling me she read about DHEA and decided not to take it. the culture also showed a commensal imbalance of alpha-hemolytic streptococcus and presence of Blastocystis hominis. She decided to take 1500 mg inositol. There also is some evidence this may be useful for treating anorexia nervosa3 and bulimia. Lifestyle: Exercise and do something fun every day to reorient your emotions as they become less tormented by bulimia. M wrote me via e-mail. she resumed vomiting within 2 days of ceasing the 5HTP. • To improve function of taste buds: Zinc. eventually ceasing all supplements. •• To increase muscle mass and bone mineral density: DHEA: 25 mg per day. •• To decrease anxiety and OCD symptoms: Inositol: 10 g per day as a starting dose. I am unable to obtain other types of testing. for 1 month: • To reduce streptococcus infection: (1) Xylitol. Follow-up Visit in 2 Weeks Three days later. a lower dose than originally recommended. please visit copyright. treatment Plan As you might expect from a naturopathic primary care provider.) Current research1 also reports PANDAS to be a clinical diagnosis. I like to keep track of patients taking homeopathy. no dysbiotics. At her follow-up appointment. once only. because by the time of the follow-up appointment. I recommended the following comprehensive treatment plan for this patient. Normally. To share or copy this article. M reported via e-mail that she was “not doing well” and has 24 Integrative Medicine • Vol. she eventually stopped taking it because it made her feel bloated and heavy. • To address other conditions indicated in laboratory tests (eg. 6 • December 2012 Barton—Bulimia and OCD . M reported that. I use a particular stool culture test that is very comprehensive and measures both normal bacteria. with no conclusive laboratory tests to support the diagnosis. so I requested a progressive stool culture without food sensitivity testing. Natrum muriaticum 30c 3-5 pellets. Use ISSN#1543953X. 250 mg twice daily. I conduct both food sensitivity tests and stool cultures in patients with a suspected hypersensitivity reaction. visit imjournal. in particular. and finally to 100 mg two times per day. To subscribe.
to give it more public attention! None of the clinicians I have consulted treated my disorder as something physical. In this case.7(1):20-22. even though I strongly felt it was. She also reported she had begun painting again and was applying to graduate school in pursuit of her Master’s degree.nih. Smith SM. Becker LA. Further Reading About PANDAS 1. visit imjournal. Thank you again for your help. Oct 2004. the naturopathic principle.zrtlab. http://intramural. streptococcal infection was most likely contributing to a chronic hyperimmune reaction in the patient. mixed connective tissue disorder. and other eating disorders.com ©2012 ZRT Laboratory. also played a key role in M’s treatment. I last heard from M a few months after her last message. http://pandasnetwork. leading to the symptoms this patient experienced (anxiety) and the behaviors she developed to cope with those symptoms (vomiting). vitiligo. please visit copyright. Kasper S. to update you on my health and to express my gratitude for everything you have done for me! You were correct about the treatment regimen you recommended: after following the regimen for one month. This could include infections such as M’s bronchitis. http://intramural. Smucny J. National Institute of Mental Health.12(6):400-443. my goal is to seek the underlying cause(s) of a patient’s condition. which was very useful in helping to reduce M’s anxiety. I have treated many conditions. including rheumatoid arthritis. lupus (systemic and discoid). the 5HTP helped provide initial symptomatic relief. psoriasis. Barton—Bulimia and OCD . Aigner M. She reported feeling very well and experienced no recurrent vomiting after evening meals.htm 2. I order a stool panel as a routine test for patients who present with any autoimmune condition. Kaye W. She researched PANDAS. Thank you!!! What better outcome could any physician seek? References 1. World J Biol Psychiatry. and social history. Cochrane Database Syst Rev. Eat Weight Disord. my 20-year eating disorder symptoms seemed to have vanished. 3. Fahey T. fibromyalgia. All rights reserved. General information.This article is protected by copyright. (I have not yet had any patients with other automimmune conditions. In this case. 2.gov/pdn/web.com resumed taking the 5HTP. and sarcoidosis. Accessed October 26. multiple sclerosis. And. Barton: I have been meaning to write to you.) When recording the patient’s health. Updated March 2012. as well as the supplements I recommended for her. I am feeling so much better and feel incredibly thankful to live without the vicious cycle of bulimia. WFSBP Task Force on Eating Disorders. Use ISSN#1543953X. LABORATORY TESTING MADE SIMPLE ZRT Laboratory www. 2002. As a naturopathic primary care physician. To subscribe.(4):CD000245. Birmingham CL. No authors listed. I also enquire about any instances of food poisoning. 2011. She learned about the importance of probiotic supplements and the key role the GI tract plays in immunity and in overall health. or prophylactic antibiotics given for dental procedures. But the underlying cause was most likely the streptococcus infection that was helped mainly by the Xylitol and the berberine. I advised M that the treatment could require up to 1 month to become effective. Discussion This particular case is interesting to me because it represents a novel approach to anorexia. bulimia.nih. in which she reported feeling well. Antibiotics for acute bronchitis. Su JC. medical. and her patience and perseverance would be beneficial. Importantly. Treasure J. and potentially to a host of other emotional and psychological conditions or autoimmune diseases.gov/pdn/web. 2012.nimh. any conditions that were treated with antibiotics.org/ Do these patient symptoms sound familiar? 7 out of 10 women complaining of low sex drive have a hormone imbalance Low sex drive? 8 out of 10 women complaining of hot ashes have a hormone imbalance Hot ashes? 2 out of 3 women complaining of depression have a hormone imbalance Depressed? 7 out of 10 women complaining of irritability have a hormone imbalance Irritable? Call 1-877-647-0323 today for world class hormone testing.com. I enquire about any illnesses the patient may have had within 1 year prior to developing the autoimmune condition. she updated me via email on a regular basis. 4. Thank you!!! I wish you could publish something more about this topic. docere (teach the patient). You have renewed my trust in doctors. The pharmaceutical medications given to help control some psychological disorders (such as bipolar disorder or schizophrenia) certainly can be life-saving for some patients and I encourage patients to use the treatment that is most effective for them. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for pharmacological treatment of eating disorders.nimh. She wrote: Dr.htm. To share or copy this article. Zinc supplementation in the treatment of anorexia nervosa. I received a follow-up e-mail from M approximately 1 month later. LLC. in this case and in all others.
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