Eating Disorders: Anorexia and Bulimia

Description

Alternative Names

Treatment for Anorexia

The treatment goals for patients with anorexia require a team approach and include the following:

• Treatment of any existing medical conditions. Physicians should immediately check and treat any medical problems related to the condition, such as bone loss, imbalances in important electrolytes, and any hormonal deficiencies, including thyroid and reproductive hormones.
• Nutritional rehabilitation.
• Psychotherapy.

Many moderately to severely ill anorexic patients require hospitalization, particularly under the following circumstances:

• When weight loss continues even with outpatient treatment.
• When weight is 30% below ideal body weight.
• When depression is severe or the patient is suicidal.
• When symptoms of medical complications (e.g., disturbed heart rate, low potassium levels, altered mental status, low blood pressure, severe sensations of cold).

In some severe cases, patients with anorexia may need to be hospitalized involuntarily. A 2000 study reported that such patients respond as well as patients who were admitted voluntarily. And, most later agreed that such treatment had been necessary.

Duration of Inpatient Treatment. For people with severe anorexia, many experts believe that 10 to 12 weeks of hospitalization with full nutritional support are required to reach ideal body weight. Unfortunately, the pressures of managed care force most patients out much earlier before they have reached even a suboptimal weight. Insurance companies rarely cover more than 15 days in the hospital, which places patients with severe anorexia at great risk for relapse and serious health consequences. It is particularly critical for women with both diabetes and anorexia to achieve 100% of ideal weight before being released.

Team Approaches. A multidisciplinary team approach with consistent support and counseling is essential for long-term recovery from all severe eating disorders. Depending on the severity and type of disorder, team members may include the following:

• Physicians specializing in relevant medical complications.
• Dietitians.
• Cognitive-behavioral therapists. (Bulimia is best treated with a combination of antidepressants and cognitive therapy.)
• Psychotherapists.
• Nurses.

All should be skilled in treating eating disorders. Studies have found that people treated by such specialists have a lower mortality rate than those treated only as psychiatric patients.

Restoring Normal Weight and Nutritional Intervention

Nutritional intervention is essential. Weight gain is associated with fewer symptoms of anorexia and with improvements in both physical and mental function. Restoring good nutrition can help reduce bone loss, and raising the level of energy available to the body by balancing food intake and exercise can normalize hormonal function. Restoring weight is also essential before the patient can fully benefit from additional psychotherapeutic treatments.

Goals for Weight Gain and Good Nutrition. One approach to weight gain involves the following steps:

• The weight-gain goal, usually one to two pounds a week, is strictly set by the physician or health professional. This goal is absolute, no matter how convincingly the patient (or even family members) may argue for a lower-weight goal.
• Patients who are severely malnourished may need to begin with a calorie count as low as 1,500 calories a day, however, in order to reduce the chances for stomach pain and bloating, fluid retention, and heart failure.
• Eventually, the patient is given foods containing as many as 3,500 calories or more a day.
• More calories than normal may be required to put on weight. In some cases, severe dieting has caused the metabolism to adapt to malnutrition and resist the effects of overfeeding. Some anorexic patients also may naturally have a higher metabolism than other individuals.
• Dietary supplements may be needed. Zinc supplementation has been shown to help increase body mass. Patients should receive calcium plus a multivitamin. Oral phosphates are also useful.
• Although eating is the problem, discussions of the disorder are never held during meals, which are times for relaxed social interaction.

Some physicians recommend cyproheptadine (Periactin), an antihistamine, which may stimulate appetite. (It is not useful for patients with bulimia and may even slow recovery.) One interesting study suggested that eating yogurt with active cultures of so-called good bacteria may boost immune factors that may help prevent infections.

Tubal Feedings. Feeding tubes that pass through the nose to the stomach are not commonly used, since many experts believe they discourage a return to normal eating habits and because many patients interpret their use as punishing forced feeding. A 2002 study reported, however, that when patients were given such tube feedings at night with oral feedings during the day, they gained twice as much weight as patients who were being fed orally only. More research is needed to see if benefits persist when patients return home.

Intravenous Feedings. Intravenous feedings may be needed in life-threatening situations. This involves inserting a needle into the vein and infusing fluids containing nutrients directly into the bloodstream. Overzealous administration of glucose solutions can trigger the so-called refeeding syndrome, in which phosphate levels drop severely and cause a condition called hypophosphatemia. Emergency symptoms include irritability, muscle weakness, bleeding from the mouth, disturbed heart rhythms, seizures, and coma.

The Role of Exercise in Recovery

The role of exercise in recovery is complex, since for those with anorexia, excessive exercise is often a component of the original disorder. However, very controlled exercise regimens may be used as both a reward for developing good eating habits and as a way to reduce the stomach and intestinal distress that accompanies recovery. Exercise should not be performed if severe medical problems still exist and if the patient has not gained significant weight.

Psychologic Approaches and Medications for Patients with Anorexia

Psychologic Therapies Used in Anorexia. Some studies suggest that for adolescents with anorexia, family therapy that employs cognitive-behavioral techniques works best. For those with late-onset anorexia, individual supportive therapy may be more effective, particularly since many people with anorexia lack a sense of self-survival. Family therapy is important for younger and older individuals. It should be noted that people with severe anorexia often have mental deficits and may not respond well to psychologic therapies until they have regained weight.

Antidepressants. Studies have not reported many benefits from selective serotonin reuptake inhibitors (SSRIs), the antidepressants that are often useful for patients with bulimia. Some SSRIs cause weight loss. Furthermore, experts fear that the effects of starvation may intensify their side effects and reduce their effectiveness. Nevertheless, few studies have actually been conducted using SSRIs in anorexia, particularly using some of the newer agents. Some, in fact, suggest that SSRIs may help prevent relapse in patients who have been treated and have restored weight. And a small study using sertraline (Zoloft) reported improvement in patients who were initially treated with the SSRI. These agents may also be specifically useful for people with anorexia who also have obsessive-compulsive disorder (OCD) or similar features. More work is needed to determine if there is a possible role for these agents.

Anti-Anxiety Agents. Patients with anxiety disorders and anorexia may also benefit from other agents that treat anxiety. [See the Well-Connected report Anxiety.]

Atypical Antipsychotics. Certain agents, called atypical antipsychotics, are currently used for schizophrenia and bipolar disorders. Not only are they useful for stabilizing mood but they also produce significant weight gain. Specific agents that may be helpful for patients with severe treatment-resistant anorexia include olanzapine (Zyprexa).

Agents to Restore Hormonal Function and Bone Density.

Oral Contraceptives. Although abnormal reproductive hormone balances appear to be more important in bone loss than low weight, the use of oral contraceptives (OCs), which contain estrogen and progestin, have had mixed results, with many showing no improvement. Still, it is important to try to restore normal menstruation in women with anorexia nervosa.

Calcium and Vitamin D. Patients should take supplements of 1,000 to 1,500 mg of calcium and a multivitamin containing 400 IU of vitamin D.

Other Agents for Restoring Bone Density. Other drugs are useful for bone restoration, including parathyroid hormone and bisphosphonates, although research on these agents have been conducted primarily on postmenopausal women.

Investigative Agents. One 2002 study reported that recombinant human IGF-I (rhIGF-I), which is a growth hormone, was effective in restoring bone, particularly in combination with oral contraceptives.

Dehydroepiandrosterone (DHEA) is a weak male hormone that is reduced in anorexia and, like estrogen, has positive effects on bone density. In a 2002 study, patients with anorexia who took DHEA experienced both improved bone density and improved psychological well-being. Long-term effects of taking DHEA are unknown. Possible adverse effects include male characteristics (acne, facial hair), unfavorable effects on cholesterol, and a possible growth-stimulating effect on breast or prostate cancer.