Click here to view next page of this article

 

Eating Disorders

Many young women or young men, start anorexic, graduate to bulimia and ultimately a binge eating disorder. First of all, there is anorexia nervosa, bulimia nervosa, and probably by now most of you have heard of binge eating disorders as well. Binge eating disorder is technically still in DSM- IV as an atypical eating disorder, but it is gaining itís own reputation. Itís actually the most common eating disorder. Among anorexic patients we have two very distinctive subtypes. One is the restrictive subtype, which is probably what you all think of when you think of when you think of anorexia; the young woman who doesnít eat, doesnít binge, doesnít purge, anything like that. Actually half of anorexic patients binge and purge quite a bit and sometimes it gets quite confusing as to whether these patients are bulimic or anorexic. As Iíll tell you a little bit about later, it does carry a certain amount of prognostics in terms of managed therapy and what patients can do to make that distinction.

In bulimia nervosa, typically you see binging and purging behavior. You can have no-purging bulimia and specifically those patients will have behaviors to compensate such as exercise, fasting, that sort of thing. There are a number of atypical eating disorders that are either things like eating and chewing and spitting out, or binging but not purging and having a fear of fatness or having the characteristics of anorexia or bulimia but not quite meeting full syndrome criteria. So thatís what we refer to as atypical.

Anorexia nervosa - probably most of you are pretty aware of the diagnostic criteria but we are going to go over it anyway. First of all, the most important diagnostic criteria probably is the refusal to maintain a minimally normal body. That may be either an adolescent who doesnít gain weight appropriately or an adult who loses down to an imperfect weight. What we mean when we say minimally normal is a little bit sketchy. Officially, itís less than 85% of expected body weight for height. That is also a little bit sketchy because there are so many different tables and charts and scales and systems you can use to calculate body weight.

Bulimia nervosa is characterized by episodic, recurrent binging which alternates with inappropriate compensatory behaviors and these behaviors are centered, as you know, around preventing weight gain or purging calories and take many different forms. We think of generally of self-induced vomiting as being the most common, but in fact many patients donít vomit. They use laxatives, diuretics,

Binge eating disorder is a new disorder and the diagnostic criteria are really being developed. But in general, it looks a lot like bulimia nervosa with recurrent episodic binge episodes but without the compensatory measures that we see in bulimia. So sometimes binge eaters might exercise a little or they might skip a meal here or there, but there really isnít that concerted effort to prevent eating. As a result, many binge eaters are actually overweight but they can be normal weight as well. People with binge eating disorder are also very distressed about their overeating and tend to either eat too quickly, eat in response to cues other than hunger cues. Theyíll eat when they are Ö when there is sort of a holiday dinner. Theyíll go downstairs afterwards and rummage through the fridge alone because they are

Iím going to touch just briefly on etiologic factors in eating disorders. Certainly these disorders are multi-factorial in etiology; biologic, psychological and cultural factors play a big role. Actually itís the biological factors that are probably the most poorly looked at. There is a hypothesis that certain serotoninergic dysregulation may be involved, especially in bulimia nervosa. Studies have found that women with bulimia are hypo-serotoninergic, whereas women with anorexia tend to be on the whole hyper-serotoninergic. Unfortunately it is not really clear if this is cause or effect. In other words, are the restrictive patterns of eating, alternating with binge eating, is that something that is contributing to changes in neurotransmitters. A genetic basis for these disorders holds some promise for showing a biological 

In terms of psychological factors, this is really a truncated list. There are obviously many factors that might lead someone to these kinds of behaviors. And I think itís probably useful clinically to think of binging and purging and disordered eating as the final common pathway for different forms of distress. Oftentimes what we find is that disordered eating serves to self-soothe or to manage affect in young women and oftentimes, sadly enough, itís the best solution patients have found to their particular source of distress. Oftentimes we find that these behaviors are replacing much more self-destructive behaviors, such as alcohol and drug abuse, cutting, burning, kind of thing. So clinically speaking, even though the behaviors carry a great deal of risk and the goal is ultimately to eradicate them, we really like to find out what purpose they are serving before we jump in and try to get rid of them. Many patients, especially with anorexia, report that 

Cultural factors are quite obvious in etiology of eating disorders. Probably in these disorders more than any other psychologic disorder. As you guys are probably aware, there are tremendous cultural pressures to be slim. Print media, televised media promote dieting. Images that young women see on television and in the print media really normalize the tremendously narrow range of normal body shapes, and they may get the idea that everybody else is thin except for them. It sets up a self comparison which, for some women, it leads to self-disparagement. There are also cultural conditions, ideas that it is good to make yourself into a better person and better is maybe thinner, that predominate in our society, that are fortunately not seen in other societies that have lower prevalence of eating 

The outcome of eating disorders is a little bit depressing. Half of the patients do get better in treatment, but you see here that anorexia nervosa has a 5.6% mortality rate per decade. This is, I believe, one of the highest mortality rates for any psychiatric disorder. Itís 12 times higher than you would expect to see among women in this age group. So something that you need to take seriously, if you have these patients in your practice. You will see here that half the patients make it somewhat down the road to recovery, but a good 10-20% really stay clinically ill.

In terms of the clinical evaluation of an eating disorder, I am going to emphasize over and over today that clinical evaluation really needs to be multispecialty. And as psychiatrists or psychologists you are really taking a part of the treatment. You might be running a team or organizing or managing a team but you really do need the input from other healthcare personnel, specifically the medical evaluation is extremely important. Especially in anorexia but also in bulimia nervosa. The first thing to do when you see a patient like this is make sure

Bulimia nervosa can present with absolutely no medical findings, but oftentimes purging behavior will lead to all sorts of complications which are important for you to be aware of. Most of these have to do with fluid and electrolyte abnormalities. Probably most importantly, low serum potassium which can lead to all sorts of problems as you know. Especially cardiac arrhythmias. Patients also complain quite a bit about constipation and sometimes need to be supported through laxative withdrawal and that sort of thing, so that 

Individuals with eating disorders, in terms of getting them to treatment, are often very reluctant to seek treatment. There is usually a lag time of several years between the time of symptoms onset and there is a diagnosis. Thatís for a variety of reasons. Unfortunately some _ 

In terms of what works, for eating disorders in terms of medical health treatment, research is kind of all over the board on this. Certainly psychotherapy works, or it helps, and it really depends. You can choose from a vast menu of different techniques. It really depends, as it always does, on patientís motivation, strengths, what kind of comorbid illness there is. What we find very helpful is a treatment contract with the patients who are anorexic, and sometimes bulimic. Because patients often get to a point where their weight drops lower and lower and who knows why that is. Maybe they are trying to get your attention, maybe they canít help it, maybe they think they donít deserve treatment unless they are really really sick. At any rate, it is useful to anticipate with a patient that she might get worse before she gets better. If her weight drops to a particular weight where she starts to Ö where her serum potassium drops to 2.4 below. Thatís arbitrary but anyway, to let her know what the parameters are for hospitalization. That does give a person control over where her treatment will take place. And itís much better to work it out in advance rather than when her weight is at a dangerously low level.

Cognitive behavioral therapy is effective for bulimia and also for binge eating disorder. Unfortunately we donít know as much about it. It works pretty well but it doesnít generally cure people. Reduction of symptoms is up to 90%, usually three-quarters to 90% of people will improve. Purging also improves. Remission rates are not as good. They are somewhere around 50-70% for binging, and unfortunately around 40-60% for purging. So it works but it doesnít work 100%. As you can imagine, itís the best studied therapy because itís the easiest to study. Itís time-limited, itís highly standardized so itís easy to see whatís going on there. Interpersonal therapy 

In terms of stimulus control, we like patients to identify what their triggers are. Usually triggers are emotional in nature, they can be environmental. The patient comes home and thereís no food in the fridge but thereís a huge box of cookies. What is she going to do? She is going to eat the cookies. Simple as it sounds, we ask patients to remove triggers and try to work their schedules around this kind of thing. Anyway, you get the idea.

Group therapy is very helpful in the eating disorder patient. Some people are worried about referring their patients because they are worried that there is going to be a whole competitive thing with who can be the thinnest, or who can be the sickest anorexic. But generally speaking, patients do very well in this modality. Family therapy, for reasons we talked about before, that these are young

On to medication management. There is kind of bad news here which is that medication doesnít do all that it is probably cracked up to do for these particular disorders. Maybe this is too general, but it is highly individualized for these patients. In other words, itís not clear that all bulimic or anorexic patients need their medication or donít need their medication. It really depends on comorbid disorders that

If you have comorbid depression or anxiety disorder that will guide you medications as well. If the patient isnít responding to psychotherapy, by all means consider medication. As always, you have to take into account patients preferences in terms of whether they want to take medication. For some reason, a lot of patients in this population are really adverse to taking medication. It really scares them. Some of them do with medication exactly what they do with food, which is they are willing to see us if they take an enema and spit

Hereís the bad news. For anorexia, there is really no specific medication that is generally useful. People have looked at antidepressants, theyíve looked at antipsychotic medication, theyíve looked anti S and D medication and nothing unfortunately is generally useful. Individually yes in some cases but not generally. Fluoxetine may be effective in anorexics who have regained their weight. If they are

About weight gain; people have tried all kinds of different agents to see if they can put weight on anorexic patients. Unfortunately none of them are routinely clinically used. Psychotropics, they do put weight on patients in some cases. I wouldnít recommend you use them.

Also, patients when they start to eat again, they get very uncomfortable and very upset about the fullness, and sometimes you can fiddle around with GI motility drugs. There is nothing that has generally been shown to really change motility. But cisapride in some cases does help patients feel a little better subjectively. It may allow them to comply better with treatment.

In terms of bulimia, there have been numerous control trials that show at least short term moderate efficacy and symptom reduction, but unfortunately remission rates are pretty low and relapse rates are pretty high. Definitely, again, use these drugs in the treatment of comorbid illness but don't expect a cure from using medication in a bulimic patient. Having said that, let me run through very quickly - and this is also summarized in your syllabus -what we recommend for medication for bulimic patients. Definitely the best studied is fluoxetine and you really need to use 60 mg a day, if itís tolerated. It is superior in studies to 20 mg a day. Fluoxetine is the only FDA approved drug for this illness. Unfortunately, no other SSRIís have been shown to be efficacious in studies, so Ö and certainly they are routinely clinically used and some older patient doesnít tolerate fluoxetine, but I would start with the one that has been studied.

In terms of tricyclics, desipramine and imipramine both have been extensively studied. Dosage ranges are standard antidepressant ranges, but patients can tolerate up to 300 mg a day. Amitriptyline has now been found effective and other tricyclics havenít even been

MAO inhibitors have been found effective. I donít recommend using them. In the studies there was a very high discontinue rate. Discontinuation rates in patients who can tolerate them, there have been studies that have shown that bulimic patients are at higher risk for hypertensive crises on these agents probably because of the dietary discretion and binge eating. Possibly because of diet pill use.

Trazodone has been studied. It is effective in bulimia. Only one study. It is sort of considered a third line agent after you have gone through the SSRIís and the tricyclics that are known to be effective. Bupropion unfortunately is effective, but we donít recommend you use it because in the only one study thatís ever been done, patients had very high seizure rates of 5%. Even at doses less than or equal to

The limitations of therapy for bulimia nervosa are many. As Iíve already pointed out, medications are usually inadequate to achieve remission. Although I have seen it. I have seen patients who have been binging and purging for 20 years, spontaneously remit without any therapy. Just medication. So it does happen. Donít know very much about monitoring income. These studies are usually done short term

Very quickly, Iím sure it will be common sense to you, but choose an agent based upon side effect profile. Many agents are useful. See what your patient tolerates. There has been really very little comparative data available in terms of what works better, so I would just go with what a patient tolerates and wants to take. If the patient doesnít respond to one medication, by all means, try another one.

Binge eating disorder: Iím not going to say much about pharmacotherapy because so little is known. Really, the only medication that clearly works is fluvoxamine. Desipramine has been studied in non-purging bulimia. Somewhat effective. Imipramine has been studied in very low doses in obese binge eaters but the data are kind of equivocal. In terms of - hereís your list, it should be in your hand out - in terms of what works for these different drugs, what we would or would not recommend, the only change is that in binge eating disorder,

If a patient has been on medication management, make sure sheís got a therapeutic dosage. Make sure sheís taking medication and sheís not purging. Figure out if her nutritional status might be contributing to her response. Think about an alternative agent and think about trying medication again later on in the therapy. Since I said that weight needs to be actively managed in this population, what I

When to hospitalize a patient with an eating disorder? Generally you can take care of them as outpatients but there are times when they need to go in. As general guidelines, I would say that when a patientís body weight is less than or equal to 75% of ideal, when there are some imminent risks of medical danger because of malnutrition, dehydration, electrolyte abnormalities, the patient is using Ipecac which