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The following medications are mentioned as undergoing research trials, but are not yet FDA approved for the disorders mentioned: sertraline (Zoloft), citalopram (Celexa), fluvoxamine (Luvox), quetiapine (Seroquel), olanzapine (Zyprexa), aripiprazole (Abilify), and naltrexone (ReVia). No commercial support was used in the development of this CME lesson. KEY WORDS: Anorexia nervosa • Bulimia nervosa • Binge eating • Interdisciplinary treatment
LEARNING OBJECTIVES: The lesson will enable clinicians to (1) identify the signs and symptoms of eating disorders,
(2) list the most common comorbid psychiatric conditions seen in eating disorders, and (3) inform patients of evidence based
treatment options for the treatment of eating disorders.
LESSON ABSTRACT: Eating disorders have the highest mortality rate of any mental illness due to either medical
complications of the disorder or suicide. The causes of eating disorders are multifactorial with a biopsychosocial basis. In
simplistic terms, they are often the result of out of control dieting. However, if it was that simple, there would be millions
more with anorexia nervosa or bulimia nervosa. As part of the illness, patients diagnosed with anorexia nervosa are
characteristically resistant to treatment. They have a distorted body image and often believe that they are overweight, fat, and
ugly, which results in a corresponding lack of motivation for recovery. Gaining weight is counterintuitive for them. Through
the bingeing and purging behaviors of patients diagnosed with bulimia nervosa, there is resultant significant damage to their
bodies. Comorbid psychiatric conditions encountered in both anorexia nervosa and bulimia nervosa include depression,
substance abuse, sexual abuse, and anxiety disorders. The complexity of identifying and treating eating disorders requires high
suspicion in patients who suddenly lose weight or stop developing. In addition, those involved in high risk activities or
involved in careers with increased pressure for weight control, such as wrestling, gymnastics, dancing, ice skating, theater, and
modeling, are at increased risk for the development of an eating disorder. Individuals who have a history of depression,
anxiety, substance abuse, or trauma often have a comorbid eating disorder. One of the goals of early treatment is simply
getting patients to realize that they are starving themselves to death. Treatment takes a team of professionals, including a
primary care provider, a dietitian/nutrition therapist, a psychotherapist and/or family therapist, and a psychiatrist. Treatment
can take place in a variety of settings, from outpatient to inpatient hospitalization, depending on the severity of the
individual’s illness.
What Are Eating Disorders?
Anorexia Nervosa
Eating disorders (EDs) have the highest mortality
Even though “anorexia” and “anorexia nervosa” are
rate of any mental illness. The mortality rate associ
often used interchangeably, they actually refer to dif
ated with anorexia nervosa is 6–12 times higher in
ferent conditions. Anorexia is a lack or loss of
women compared with the overall death rate (all
appetite for food. Anorexia nervosa, on the other
causes) when adjusted for age. About 5%–10% of
hand, is a clinical disorder in which someone refuses
anorexic patients die within 10 years from the onset
to maintain even a minimally normal ideal weight.
of the illness, 18%–20% die within 20 years, and
People with anorexia nervosa have a fear of gaining only 50% report ever being cured.1
weight, which paradoxically intensifies as they continue Eating disorders are complex illnesses that develop to lose weight. Despite significant weight loss, they con over time from a combination of psychological, inter tinue to have body image distortions and consider them personal, cultural, and physiological factors, resulting in a disturbance of thoughts and behaviors about food and Menstrual irregularities or absence of menses weight, as well as an excessive concern about body shape becomes an issue in females diagnosed with an eating or weight. These disorders are progressive in nature, disorder. In girls who have not reached menarche, men affect males and females, and can have life threatening strual cycles are often delayed. If a female is using hor consequences. Currently, the prevalence of eating disor mone replacement therapy or birth control pills, she ders in the United States is approximately 0.9% for may continue to have menses even though she is signifi anorexia nervosa and 2%–3% for bulimia nervosa.
cantly underweight. The DSM IV TR suggests a body Binge eating is at least as prevalent as bulimia nervosa weight <85% of the ideal weight to make a diagnosis of and may be prevalent in as up to 8% of obese patients.2 anorexia nervosa. Weight loss is managed by restricting Eating disorders are classified as a psychiatric disorder caloric intake or fasting, by exercising excessively, and/or in the Diagnostic Manual of Mental Disorders, 4th Edition, Text Revision (DSM IV TR).3 They are classified into There are two subtypes of anorexia nervosa. Most three major categories. Two specific types are anorexia common is the restricting subtype in which the affected nervosa and bulimia nervosa. The DSM IV TR also has a individuals restrict their calories, fast, and often starve.
category called eating disorders not otherwise specified The second subtype is binge eating/purging type in (EDNOS; e.g., anorexia nervosa, bulimia nervosa, and which the patients generally restrict their food intake eating disorders not otherwise specified). This last cate but have periods of binging and/or purging. Some gory is more common than others as EDNOS may repre anorexics of this subtype do not binge at all but will sent a combination of both anorexia and bulimia in purge almost everything they eat. While this may sound patients who do not meet the criteria for either disorder like bulimia nervosa, the key is that the individual with alone. One third to one half of patients diagnosed
binge/purge type of anorexia will still meet all criteria for with anorexia nervosa will go on to develop bulimic
anorexia nervosa as listed in the DSM IV TR below.
symptoms and may shift between both disorders in a
chronic fashion.
DSM-IV-TR Criteria
The DSM V,4 which is projected for release in May for Anorexia Nervosa (AN)
2013, will have just a few changes. Amenorrhea will beeliminated altogether in anorexia nervosa. Binge eating Criteria:
disorder (BED) will be added as a distinct diagnostic cat Refusal to maintain body weight at or above
egory. There is insufficient evidence to have psychiatric a minimally normal weight for age and
diagnosis for obesity and overeating. The bulimia ner height, for example, weight less than 85% of
vosa criteria will allow the diagnosis to be made when that expected or failure to make expected
the binge/purge frequency is once a week instead of weight gain during period of growth, lead
Eating Disorders: Not Just a Diet Gone Wrong ing to body weight less than 85% of that
type occurs when the individual engages in cycles of expected.
caloric restriction/fasting and/or excessive exercising.
Bulimia nervosa shares some characteristics with Intense fear of gaining weight or becoming
anorexia nervosa. Both bulimics and anorexics have a
fat, even though underweight.
distorted body image, often thinking that they are
Disturbance in the way one's body weight
fat, disliking their body shape, and seeing themselves
or shape is experienced, undue influence of
as unattractive. In addition, the anorexia nervosa
body weight or shape on self evaluation, or
binge eating/purging subtype is marked by episodes
denial of the seriousness of the current low
of binging and/or purging.
body weight.
In postmenarcheal females, amenorrhea—
DSM-IV-TR Criteria
the absence of at least three consecutive men
for Bulimia Nervosa (BN)
strual cycles. A woman having periods only
while on hormone medication (e.g., estro
Criteria:
gen) still qualifies as having amenorrhea.
Recurrent episodes of binge eating charac
terized by both:
Eating, in a discrete period of time (e.g.,
Restricting Type: During the current episode
within any 2 hour period), an amount
of anorexia nervosa, the person does not
of food that is definitely larger than
regularly engage in binge eating or purging
most people would eat during a similar
behavior (self induced vomiting or misuse
period of time and under similar cir
of laxatives, diuretics, or enemas).
cumstances.
Binge Eating/Purging Type: During the cur
A sense of lack of control over eating
rent episode of anorexia nervosa, the person
during the episode (such as a feeling
regularly engages in binge eating or purging
that one cannot stop eating or control
behavior.
what or how much one is eating).
Recurrent
inappropriate
compensatory
Bulimia Nervosa
behavior to prevent weight gain, such as
self induced vomiting, misuse of: laxatives,
Bulimia nervosa differs from anorexia nervosa pri
diuretics, enemas, or other medications,
marily because the former lacks episodes of starving.
fasting, or excessive exercise.
Instead, bulimics engage in episodes of binge eating
followed by frequent calorie limiting compensatory
The binge eating and inappropriate com
mechanisms. A purge is a way for patients to get rid of
pensatory behavior both occur, on average,
the calories from the binge. Patients often report that at least twice a week for 3 months.
there is nothing enjoyable about a binge, but the relief Self evaluation is unduly influenced by
and satisfaction comes from the purging behavior. Com body shape and weight.
pensatory measures most commonly include selfinduced vomiting but may also include excessive use of The disturbance does not occur exclusively
laxatives or diuretics. Fasting and exercising excessively during episodes of anorexia nervosa.
are types of purging behaviors as well. In fact, bulimianervosa may be subclassified as a purging type when the individual regularly engages in self induced vomiting, Purging Type: During the current episode of
laxative abuse, and/or diuretic abuse. The nonpurging bulimia nervosa, the person regularly
engages in self induced vomiting or the mis
behavior after eating small amounts of food
use of laxatives, diuretics, or enemas.
(e.g., self induced vomiting after consuming
two cookies).
Nonpurging Type: During the current episode
of bulimia nervosa, the person uses other inap
Repeatedly chewing and spitting out, but
propriate compensatory behaviors.
not swallowing, large amounts of food.
Binge eating disorder refers to recurrent
Eating Disorder
episodes of binge eating in the absence of a
Not Otherwise Specified
regular inappropriate compensatory behav
ior characteristic of bulimia nervosa.
Eating disorders not otherwise specified (EDNOS) is thethird category of eating disorders. The DSM IV TR Two other types of disordered eating that will only states that EDNOS is for eating disorders not meeting be briefly mentioned here include binge eating disorder the criteria for any specific eating disorder. It is impor tant to note that someone can still have an eating disorder or body image issues and not meet the diagnostic Binge Eating Disorder
criteria. Furthermore, not meeting the full criteria for
anorexia nervosa or bulimia nervosa does not mean
BED, sometimes referred to as “compulsive overeating,” that the symptoms are less severe. Up to 50% of
is believed to be the most common eating disorder and patients with an eating disorder meet the EDNOS
affects millions of Americans. Similar to bulimia ner
criteria, making it the most common of all the eating
vosa, those with binge eating disorder frequently
disorders.
consume large amounts of food while feeling a lack
of control over their eating. They often eat when not
DSM-IV-TR Criteria Eating
hungry, as well as in secret. However, this disorder is
Disorders–not Otherwise
different from bulimia nervosa because people with BED usually do not engage in compensatory measures Specified (ED-NOS)
to get rid of their food (e.g., vomiting, laxatives, etc.).
EDNOS includes eating disorders that do not meet the BED is believed to affect 1%–5% of the population and criteria for any specific eating disorder. Examples is often associated with being overweight or obese. Addi tionally, these patients often suffer from depression. Aspreviously mentioned, BED is expected to be catego For female patients, all the criteria for
rized in the DSM V as a distinct disorder.5 anorexia nervosa are met except that the
patient has regular menses.
Night Eating Syndrome
All the criteria for anorexia nervosa are met
except that, despite significant weight loss,
1.1%–1.5% of the general population, 6%–16% of the patient's current weight is in the normal
patients in weight reduction programs, and 8%–42% of candidates for bariatric surgery. This condition is All the criteria for bulimia nervosa are met
defined as evening hyperphagia (eating greater than except that the binge eating and inappropri
25% of the total daily calories at night) and staying ate compensatory mechanisms occur less
awake at night accompanied with eating, usually in than twice a week or for less than 3 months.
insomniac patients. Night eating syndrome may precede obesity.6 The patient has a normal body weight and
regularly uses inappropriate compensatory
Eating Disorders: Not Just a Diet Gone Wrong Risk Factors and Prevalence
mood, and impulse control. There are reduced 5 HT2A for Eating Disorders
receptors and increased 5 HT1A receptors in bothpatients with active eating disorders and patients in Biological Factors:
recovery from an eating disorder. Compulsive eating andcompulsive drug seeking in drug addiction have a signif The cause of eating disorders is very complicated. While icant overlap correlation. In some obese patients, there is the ultimate etiology of eating disorders remains a reduction in ventral striatal dopamine. The lower the unknown, they appear to result from a complex interac number of D2 receptors, the higher the weight. It is tion of biological and environmental risk factors, includ hypothesized that some obese patients may eat to ing familial, psychological, developmental, and social increase these reward circuits.10 The prevalence of eating disorders and substance use disorders in females shows The greatest risk factor for developing an eating
that up to 55% of individuals with bulimia nervosa disorder comes from being female. Women and ado
abuse alcohol or illicit drugs, and 27% of those with lescent girls have a nearly five to eight times higher
anorexia nervosa abuse alcohol or drugs, compared with rate of an eating disorder diagnosis than males. First
9% of the general population. Conversely, up to 35% of degree relatives of patients with anorexia have a signifi alcohol or illicit drug abusers have eating disorders com cantly increased prevalence of eating disorders, report edly as high as 29%. Children of patients with anorexianervosa have a 5% risk of developing anorexia nervosa.
Hormonal Influences
Children of patients with bulimia nervosa have a higherrate of eating disorders and substance abuse—particu Puberty itself is speculated to be a trigger for the devel larly alcoholism as well as mood disorders and obesity.7 opment of anorexia nervosa. Approximately 40% of
Like many other complex disorders, eating disorders new cases occur in girls ages 15–19. Also, young
most likely have a polygenetic etiology, with each gene female athletes may be at significant risk for
having some effect. The genetic contribution is consid anorexia. Exercising and dieting may “turn on” the
ered to be 40%–60%. Patients diagnosed with an eating eating disorder genes. Testosterone appears to decrease
disorder have several genetic traits that make them the development of an eating disorder, which may be prone to develop such a disorder. These traits include related to the observation that women have a five to anxiety, perfectionism, and low self esteem.8 In fact, eight times higher rate of developing eating disorders 59% of patients diagnosed with an eating disorder have had a premorbid diagnosis of anxiety disorder, and 67%had a lifetime prevalence.
Psychosocial Factors
Parental attitudes toward eating, weight, and body shape Physiological and
strongly influence how children respond to food and Neurobiological Factors
body image. (However, parents are generally not to Starvation releases endogenous opioids that may con blame for their child developing an eating disorder.) A tribute to the apparent ease in which anorexic patients child’s perceived pressure to be thin and criticisms from deny their hunger. Binging and exercising also increase parents or siblings regarding weight issues strongly affect circulating levels of B endorphins, which are chemically a child’s body image and self worth. The role models for identical to exogenous opiates. Endorphins are poten children and young adults, such as fashion models and tially addictive because of their ability to stimulate celebrities, have gotten thinner over the years. The ado dopamine in the brain’s mesolimbic reward centers.9 lescents’ or children’s first diet is often triggered by a There is also evidence to suggest that serotonin in the comparison with others and their own thin ideal. Media brain contributes to the dysregulation of appetite, influences can directly cause body dissatisfaction and dieting or abnormal eating. A study conducted in Fiji the eating disorder or was a result of the eating disorder.
before and after the introduction of satellite TV to the Clearly, the treatment of depression in patients with an island showed a significant increase in eating disorder eating disorder includes weight restoration and normal behavior and body dissatisfaction in a very short time ization of eating behaviors. Trauma has shown higher rates of posttraumatic stress disorder (PTSD) than Abuse has been associated with eating disorders in expected in patients with eating disorders. In one study, both women and men. Sexual abuse is a significant 74% of women attending residential treatment indi trauma and has been estimated to occur in up to 30% of cated that they had experienced significant trauma, and patients diagnosed with an eating disorder. Bullying, 52% reported symptoms consistent with a diagnosis of another form of abuse, has also contributed to the devel PTSD.14 Substance abuse has been seen in approxi opment of eating disorders in many patients. Individuals mately 55% of patients with bulimia nervosa and 27% with a substance use disorder are at higher risk for bulimia; those with depression, anxiety, and a history oftrauma are at higher risk for both anorexia and bulimia.
Identification of Eating Disorders
There are certain sports in which eating disorders For a psychiatrist, the majority of patients with anorexia are prevalent. The female athlete triad is recognized in
are seen by a primary care provider first for menstrual athletic women with an eating disorder and mani
irregularity or significant weight loss. Oftentimes, fests as amenorrhea, low body weight, and low bone
patients deny that they have an eating disorder, stating density. For women, sports more prone to precipitate
that they are just trying to lose weight. For a list of anorexia include those that require or favor a slim
screening questions that can be easily administered in a appearance, such as gymnastics, figure skating, and
busy office practice to help determine if a patient has an diving. Ballet can also be a causative factor. Cross
country and marathon running also emphasize slim
ness for performance. For men, low weight crew,
Medical Evaluation of an
low weight wrestling, cycling, and rock climbing
demand slimness; diving and figure skating also
Eating Disorder and Promotion
emphasize slimness and appearance. Eleven Division I
of a Healthy Body Image
schools surveyed athletes from a variety of sports includ All patients suspected or diagnosed with an eating disor ing football, wrestling, gymnastics, crew and Nordic ski der should have a complete medical examination. The ing, about eating disorder behaviors and self perception.
screening questions above are just initial questions. This Three percent of females were identified as having examination should include a full physical examination.
anorexia versus 0% males, and 9% of females were iden Clearly, the presentation of anorexia nervosa is different tified as having bulimia versus 0.1% males. Eleven per from that of bulimia nervosa. In fact, the physical exam cent of females and 13% of males reported binge eating ination and laboratory findings in a patient with bulimia When medically approaching a person who has expe Psychiatric Co-occurring
rienced significant weight loss, you suspect the person Conditions
may have an eating disorder if they are unconcernedabout their weight loss; they continue to exercise—often Anxiety and depressive disorders are the most common excessively—and do not complain about fatigue. The
comorbid psychiatric conditions seen in patients diag most common cause of weight loss in adolescents is
nosed with an eating disorder. Anxiety disorders were dieting or anorexia nervosa, not malignancies, dia
identified in 59% of patients before they had an eating betes, or chronic infections. However, in the appropri
disorder, and nearly 67% have lifetime prevalence. As ate patient presentation, these may necessitate further with many chronic illnesses, depression is seen as well. It is often difficult to sort out if the depression came before Eating Disorders: Not Just a Diet Gone Wrong Vitals: orthostatic blood pressure,
pulse, respirations, and temperature
Screening Questions for the
Diagnosis of Eating Disorders
Examination of the mouth and teeth,
skin, cardiac, abdomen, and extremities
General questionsabout weight:
Laboratory testing
How do you feel about your current weight? Serum electrolytes, glucose, calcium,
magnesium, phosphorus, and albumin
Do you or your family/friends have any concernsabout your eating or exercising behaviors? What is the heaviest weight you gained so far?How tall were you then? When was that? Complete blood count with differential
Diet history:
Liver function tests (SGOT, SGPT, and
What types of dieting or weight management bilirubin)
Serum BUN and creatinine
Thyroid function tests (T3, T4, and
Do you use laxatives, diet pills, diuretics, or ipecac? Exercise:
Urinalysis
• How much do you exercise? How often? Level of Stool guaiac
Menstrual history:
• Age of menarche? Regularity of cycles? LMP?• Are you on birth control or hormone replacement DEXA (dual energy X ray absorptiome
try)—measurement of bone density
Social history:
• Sexual history? History of physical or sexual abuse? • Family history of eating disorders, depression, anxiety, Medical Evaluation of a
mental illness, obesity, and substance abuse.
Patient with Anorexia Nervosa
Review of medical systems/symptoms:
• Specific to weight loss, lanugo hair, dehydration, In the medical evaluation of a patient with anorexia, the constipation, diarrhea, abdominal pain, GI complaints most striking physical findings are extreme weight loss, in general, epigastric pain, and menstrual irregularities.
muscle wasting, and muscle weakness. Hair losses fromthe scalp and lanugo hair on the body are also very com Evaluating a Patient
mon. Table 2 shows a summary of the physical signs and with an Eating Disorder:
A body mass index (BMI) < 18.5 is considered under Below is an outline of specific parameters to look for in a weight. While the BMI is not the best measure for the patient with anorexia. A good history and physical ideal weight range, it is easy to calculate. Another method examination results will rule out most medical causes of to estimate the ideal body weight (IBW). This measure weight loss and will point you in the direction of an eat ment is a simple formula developed by Dr. G. J. Hamwi ing disorder. Naturally, the height and weight are where and has been popular since the mid 1960s. As an exam one would begin. If this is an adolescent and you have ple, suppose you have a female patient who is expected to growth charts, this can be helpful to trend the weight weigh 100 pounds if she is 5 feet tall, with an additional 5 pounds for every inch over 5 feet. If a patient is 5 foot 7 Physical examination
inches, she is expected to weigh approximately 135pounds. If a patient weighs 85% or less of their IBW, this Height, weight
is one criterion for anorexia nervosa.
weigh more or to control their appetite by keeping their Physical Signs and Symptoms in
Calcium, magnesium, potassium, and phosphate Patients with Anorexia Nervosa
need to be closely monitored when the patients start to Physical signs and symptoms:
restore their weight in an effort to avoid the refeeding Extreme weight loss or flattening of growth curveon a growth chart in an adolescent syndrome. The refeeding syndrome occurs when
patients who are medically compromised due to star
vation begin to refeed too quickly. When refeeding,
the carbohydrates ultimately lead to the release of
insulin, which in starved patients leads to deficien
cies of calcium, magnesium, potassium, and phos
(complains of dizziness and light headednessespecially when getting up from lying down) phate. This may ultimately lead to cardiovascular
collapse16 but can be prevented by stabilizing the
deficiencies first and refeeding slowly, with contin
ued monitoring of magnesium, phosphate, and
potassium.
Laboratory findings seen
Bone density screening is recommended for women in patients with anorexia nervosa:
with 6 months or more of being diagnosed with anorexia nervosa. The treatment of low bone density in this population of patients is unclear. Hormone replace ment therapy has not been helpful in young patients diagnosed with an eating disorder. Weight restoration Bradycardia, hypotension BP, 90/60 mm Hg, until the return of menses, along with diet fortified with calcium and vitamin D, is the current treatment Medical Evaluation of a
Moreover, patients with malnutrition and dehydra Patient with Bulimia Nervosa
tion will have abnormal vital signs. If the pulse increases Bulimic patients may not have any obvious physical more than 20 beats/min and the blood pressure (BP) findings on history or physical exam (see Table 3). The drops more than 10 mm Hg upon standing from a most common findings include perimolysis, erosion of seated position, further follow up is warranted because the enamel of the teeth (up to 40%), sialadenosis, these measures are pathologic. Temperature regulation is enlargement of the parotid glands (10%–50%), and ele often poor in anorexia, and patients often have tempera vated amylase (10%–66%). Angular cheilosis and gin tures under 97oF. Pulse is frequently under 60 bpm.
Laboratory findings are often very confusing unless Russell’s sign refers to the presence of scars and cal you are familiar with the population. The data are sum luses on the dorsum of the hand due to the placement of marized in Table 2. Often, there is elevated cholesterol the hand into the mouth for self induced vomiting. This level, which necessitates putting the patients on low cho is a commonly observed sign. Complaints of gastroe lesterol diets. There are often abnormalities in the thy sophageal reflux disease, fatigue, and lethargy are also roid, leading to the use of thyroid replacement. Anemia common, though nonspecific. Orthostatic vitals with and leukopenia are due to the malnutrition and con pulse elevation from lying to standing, as seen in tribute to fatigue and increased risk of infections in the population. Hyponatremia is often due to excessive Laboratory abnormalities typically show hyperamy water consumption as these patients try to appear to lasemia, hypokalemia due to self induced vomiting, lax Eating Disorders: Not Just a Diet Gone Wrong expand restrictive diets. Many of these patients report upon assessments that they are vegan or vegetarian.
Physical Signs and Symptoms in
However, majority of these patients have chosen a Patients with Bulimia Nervosa
pseudo vegetarian lifestyle simply as a way to reduce Physical signs and symptoms:
calories by eliminating animal protein sources, such as Perimolysis—dental enamel erosion on the inneraspects of the front teeth beef, and not replacing with vegetable protein sources, Parotid hypertrophy—swollen salivary glands such as peanut butter or tofu. This needs to be closely Russell’s sign—scars/calluses on the dorsum of the hand (due to the placement of the hand in themouth to self-induce vomit) For anorexia nervosa, the weight gain goals depend on the condition of the patient at the time of the treat ment. If a patient is greater than 85% of their ideal May see evidence of self-injurious behavior (scars,cuts, or scratches on arms, thighs, and abdomen) weight, this can be tried as in outpatient with a weight gain goal of 0.5–1 pound a week. Nutritional counsel ing, coupled with close monitoring of weight gain, is imperative to the treatment process.
For a patient who weighs less than 85% of their ideal Laboratory findings seen in patients
body weight, gaining weight as an outpatient is more with bulimia nervosa:
challenging. Addressing the refeeding syndrome needs coordination between nutrition and primary care for close monitoring, as well as family support. This is whythese individuals are best managed in a specialty inpatient setting. The goals for weight gain in an inpatient ative and diuretic misuse, and hypernatremia. Stabiliza unit are 2–4 pounds a week. This often requires caloric tion of the laboratory findings is critical and necessary as consumption of 3000–3500 kcal/day or a maximum of bulimic purge behaviors are controlled.
70–100 kcal/kg of body weight. The use of a nasogastrictube can be helpful in the inpatient setting if it is not Treatment of Eating Disorders
used punitively. Refeeding can take place at night, and a Patients diagnosed with an eating disorder do not want patient can get up to 1800 kcal while sleeping and then to gain weight. Many patients are often very resistant to consume 1200–2000 kcal orally during the day.
interventions, as denial is a hallmark of this disease.
In both an inpatient and an outpatient setting, meal After medical assessment and clearance, the initial goal is coaching is a must. This not only allows careful moni medical stabilization. Eating disorder professionals toring of patients, but is also a chance to model a “nor include a team of individuals who are trained and have mal” eating behavior. After meals, processing feelings experience in working with this population. With a about the meal can be useful because the meal time is team approach of medical therapy, nutritional therapy, often associated with increased anxiety in most patients.
individual therapy, family therapy, and pharmacother Every supervised meal is an opportunity for an exposure apy, there is hope and the possibility of a full recovery.
therapy session. Bathroom monitoring after meals is Although 50% of individuals fully recover, sadly 10% especially important in patients with bulimia nervosa die in the first 10 years of their illness.
and purging history. Often, 1 2 hours after meals, the Weight restoration generally requires the assistance bathrooms are monitored for purging behaviors.
of a dietitian or a nutrition therapist. Nutrition therapists specialty trained in working with eating disorder Psychotherapy:
patients can be of great assistance. In addition to helping Many models of psychotherapy have been used in the their patients counter food rituals, they can dispel incor treatment of eating disorders. Clearly, family involvement rect beliefs regarding high calorie foods and work to is necessary because this is a disease that starts very early.
As described above, when approaching a psy the parents monitor all the meals. Family based therapy chotherapy patient diagnosed with an eating disorder, has been shown to be more effective than other forms of the question is where to start. After general medical and therapy in adolescents with anorexia nervosa. This psychiatric stabilization, many patients with eating dis modality is beneficial for families able to participate, orders have anxiety disorders, obsessive compulsive dis most notably those with whom the patient still lives and order, depression, and or substance abuse, which should will not be leaving home in the near future.
be concurrently addressed along with the eating disorder. A large percent have posttraumatic stress disorder, Psychotropic Medications:
and others have been victims of bullying. Below is a list More than any other psychiatric illness, eating disorders of various therapies found helpful in treating patients are largely resistant to pharmacological intervention.
with eating disorders and the co occurring psychiatric There are currently no FDA approved medications
disorders. Individual psychotherapy may include: for anorexia nervosa. One would think that antidepres
Behavior therapy
sants would be the first line treatment for anorexia nervosa because they are the first line treatment for frequent Exposure with response prevention (ERP)
comorbid psychiatric illnesses, such as depression, anxi Cognitive behavior therapy (CBT)
ety, obsessive compulsive disorder, and bulimia nervosa.
Research has shown that psychotropic medications are Dialectical behavior therapy (DBT)
helpful in some patients with comorbid conditions, how Psychodynamic therapy
ever their use as a whole has been largely disappointing inthis patient population. Perhaps their most effective role Interpersonal psychotherapy (IPT)
is once weight restoration has occurred.
Motivational enhancement therapy/
The simplest marker to measure in treating a patient motivational interviewing (MI)
diagnosed with anorexia nervosa is weight gain. Thechallenge comes in trying to convince an anorexic Psychoeducation
patient to take a medication that may make her gain Supportive therapy
weight. A concern is that if the weight gain is purelyfrom the medication, would the patient lose weight if they stopped the medication? Studies have been donewith several antidepressants, with a meta analysis evalua tion of the efficacy of antidepressants in treating Psychodynamic
anorexia nervosa, concluding that there was no significant evidence that antidepressants were better than Psychoeducational
placebo for improving weight gain or eating disorder Interpersonal
In a study in weight restored anorexic patients, it was shown that adding fluoxetine (Prozac) to CBT had Family-based Therapy (Maudsley):
no significant improvement in anorexic patients who One unique therapy showing evidence based on the had CBT therapy alone.19 Studies have been conducted treatment of anorexic adolescents is family based ther on other medications such as sertraline (Zoloft) and apy or the Maudsley approach. This is an intensive out citalopram (Celexa), with no significant drug effect on patient treatment where parents play an active role to weight gain in an outpatient setting.
help restore their child’s weight to normal levels. The Bupropion (Wellbutrin) is a different type of medica next expectation is for parents to be able to give control tion compared to the selective serotonin reuptake inhibitors over eating back to the adolescent. This is done in the (SSRIs) because the former has noradrenergic and home and monitored by a therapist. In the beginning, dopaminergic reuptake inhibiting effects. It shows a sig Eating Disorders: Not Just a Diet Gone Wrong nificant response in patients with bulimia nervosa in eating disorders. Basically, the more medically and psy binge eating and purging, but it has a high seizure rate in chiatrically stable, the lower the level of care. A patient these patients. Moreover, the FDA put a black box warn diagnosed with bulimia nervosa is often first seen in an ing on this medication for eating disorder patients in gen outpatient or partial hospital setting. Patients with med eral, particularly patients binge eating and purging.
ical compromise necessitate hospitalization and acute Medications that are undergoing research trials for stabilization. If a patient is not progressing at a lower the treatment of eating disorders include antidepressants level of care, they then meet the criteria for a higher level such as sertraline (Zoloft), citalopram (Celexa) and flu of care. The levels of care are (in order of lower to higher voxamine (Luvox). They have shown some promise in level) outpatient, intensive outpatient (meeting several decreasing binge episodes. In addition, second genera days a week for several hours a day), partial hospitaliza tion antipsychotics such as quetiapine (Seroquel) have tion (meeting 5–7 days a week for 6–12 hours a day), had favorable improvement in BMI in adolescents.
residential (7 days a week, 24 hour nursing care avail Olanzapine (Zyprexa) has been shown to help patients able), and inpatient hospitalization care.
with anorexia nervosa for body image disturbance, The following warrants inpatient hospitalization:21 Wt.
weight gain and cognition. Other atypical antipsychotics <85% IBW, HR near 40, orthostatic BP changes > 20 bpm such as aripiprazole (Abilify) are being reviewed for the HR or >10 mm Hg drop of diastolic BP, BP <80/50 mm treatment of anorexia nervosa as well as naltrexone Hg, hypokalemia, hypophosphatemia/hypomagnesemia, (ReVia) for binge/purge behavior in bulimia nervosa.
The only FDA approved medication for an eat
ing disorder is fluoxetine. Fluoxetine has an approval
for bulimia nervosa and shows a 45% reduction in
The goal of the treatment team is to get the patient diag binging and a 29% reduction in vomiting when pre
nosed with an eating disorder to first realize that they are scribed at 20 mg/day. At 60 mg/day, fluoxetine shows a
starving themselves and then to help them achieve med 67% reduction in binging and a 56% reduction in vom ical and psychiatric stability. The treatment of eating dis orders includes a team of experts. There is resistance togetting well, resistance to taking medications, resistance Levels of Care
to therapy, and resistance to giving up the ineffective The key to the management of an individual diagnosed behaviors. That being said, with a team approach of with an eating disorder is to find the correct level of care, medical therapy, nutritional therapy, individual therapy, which ranges from inpatient hospitalization to outpatient family therapy, and pharmacotherapy, there is hope and treatment. The criteria for anorexia nervosa are clear as the possibility of a full recovery. Fifty percent of individ the symptoms of medical compromise are more apparent uals fully recover; however, sadly enough, 10% die in the than in a patient diagnosed with bulimia nervosa. Special first 10 years of their illness. Early identification and ized treatment programs throughout the United States intervention in high risk groups—females, athletes, offer varied levels of eating disorder treatment.
models, actors, and high school and college females— The American Psychiatric Association Practice may improve the outcomes. Finally, after medical stabi Guidelines for the Treatment of Patients with Eating lization, treating the comorbid psychopathology, includ Disorders has a level of care guidelines for patients with ing substance abuse and trauma, is necessary.
About the Faculty
Kevin Wandler, MD: Dr. Wandler is an Assistant Professor of Psychiatry, Internal Medicine and Pediatrics; Director of the
Eating Disorder Recovery Center in the Department of Psychiatry, College of Medicine at the University of Florida in
Gainesville, FL.
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