Eating Disorders Anorexia Nervosa Anorexia Nervosa Bulimia Nervosa Bulimia Nervosa Eating Disorder...
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Transcript of Eating Disorders Anorexia Nervosa Anorexia Nervosa Bulimia Nervosa Bulimia Nervosa Eating Disorder...
Eating DisordersEating Disorders Anorexia NervosaAnorexia Nervosa
Bulimia NervosaBulimia Nervosa Eating Disorder NOSEating Disorder NOS
Nichole Grier MDNichole Grier MDUNC Dept. of PsychiatryUNC Dept. of Psychiatry
What is “normal” eating?What is “normal” eating? How do you know if you are “fat” or How do you know if you are “fat” or
“too thin”?“too thin”? When is it a “mental illness”?When is it a “mental illness”? Does anyone talk about it?Does anyone talk about it? How common is it?How common is it? Whose fault is it?Whose fault is it? Who recovers?Who recovers? How?How?
What is Healthy Eating?What is Healthy Eating?
•Mindful: Know the difference between physical and emotional cues and needs. Eat when you are hungry; stop when you are full. Meet your body’s needs.
•Enjoyable: Eat pleasurable foods without guilt or anxiety.
•Flexible: Be able to eat needed amount in available time. No calorie counting. Eat a variety of foods. Don’t avoid any food group. Try new things without knowing all ingredients.
Defining “Healthy” WeightDefining “Healthy” Weight PediatricsPediatrics
Standard: 50Standard: 50thth Percentile BMI-for-age, CDC Percentile BMI-for-age, CDC growth charts for USgrowth charts for US
Utilize height and weight history to plot growth on Utilize height and weight history to plot growth on BMI-for-age chart to establish individualized goalBMI-for-age chart to establish individualized goal
AdultsAdults Standard: Medium frame, 1983 Metropolitan Standard: Medium frame, 1983 Metropolitan
Height/Weight Tables, or BMIHeight/Weight Tables, or BMI Set minimum goal for BMI 19.5Set minimum goal for BMI 19.5 Individualize based on premorbid weight, Individualize based on premorbid weight,
resumption of menses, physical health indicatorsresumption of menses, physical health indicators
What about fat . . .What about fat . . .
The American College of Sports Medicine The American College of Sports Medicine (ACSM) recommends that males age 16 and (ACSM) recommends that males age 16 and under with < 7% body fat and males over 16 under with < 7% body fat and males over 16 years of age with < 5% body fat not be allowed years of age with < 5% body fat not be allowed to compete unless they have medical clearance. to compete unless they have medical clearance.
The ACSM recommends 12%-14% body fat as The ACSM recommends 12%-14% body fat as
the minimum safe percent body fat for high the minimum safe percent body fat for high school girls. school girls.
some historical context . . .some historical context . . .
““Anorexia Nervosa” was first described Anorexia Nervosa” was first described as a distinct diagnostic entity in 1873as a distinct diagnostic entity in 1873
““Bulimia Nervosa” became a diagnostic Bulimia Nervosa” became a diagnostic category in 1979 category in 1979
Keyes studyKeyes study
Healthy malesHealthy males Voluntary starvation then refeedingVoluntary starvation then refeeding Development of apathy, ritualistic Development of apathy, ritualistic
behaviors, preoccupation with foodbehaviors, preoccupation with food Physical symptoms cold intolerance, Physical symptoms cold intolerance,
edema, slowed heart rate, diminished edema, slowed heart rate, diminished sexual interestsexual interest
Increased caloric needs with refeedingIncreased caloric needs with refeeding Onset binge urgesOnset binge urges
DSM-IV criteria:DSM-IV criteria:
Anorexia NervosaAnorexia Nervosa RefusalRefusal to maintain body weight at or above that to maintain body weight at or above that
expected for age & height (<85%)expected for age & height (<85%) Intense Intense fearfear of gaining weight or becoming fat of gaining weight or becoming fat DisturbanceDisturbance in the way one’s body size is in the way one’s body size is
experienced, OR undue influence of body size on experienced, OR undue influence of body size on self evaluation, OR denial of seriousness of low self evaluation, OR denial of seriousness of low weight.weight.
Amenorrhea in postmenarcheal females (absence Amenorrhea in postmenarcheal females (absence of 3 or more consecutive menstrual cycles)of 3 or more consecutive menstrual cycles)
Anorexia Nervosa: SubtypesAnorexia Nervosa: Subtypes
Restricting TypeRestricting Type: : during current episode during current episode of AN, no regular binge eating or purging of AN, no regular binge eating or purging behaviorbehavior
Binge-Eating/Purging TypeBinge-Eating/Purging Type: : during during current episode of AN, regular binge current episode of AN, regular binge eating or purgingeating or purging
Anorexia nervosa is not a Anorexia nervosa is not a disorder of appetite.disorder of appetite.
May report decreased appetiteMay report decreased appetite
Others FEAR appetiteOthers FEAR appetite
DSM-IV criteria:DSM-IV criteria: Bulimia NervosaBulimia Nervosa
Recurrent episodes of binge eatingRecurrent episodes of binge eating objectively a large amount of foodobjectively a large amount of food individual feels “out of control”individual feels “out of control”
Recurrent compensatory mechanismsRecurrent compensatory mechanisms self-induced vomitingself-induced vomiting laxative uselaxative use FastingFasting excessive exerciseexcessive exercise
DSM IV criteria: DSM IV criteria:
Bulimia Nervosa Bulimia Nervosa
Binge/Purge episodes occur, on average, at Binge/Purge episodes occur, on average, at least two or more times a week for at least least two or more times a week for at least three monthsthree months
Self-esteem unduly influenced by Self-esteem unduly influenced by weight/body shapeweight/body shape
Current weight does not meet criteria for AN Current weight does not meet criteria for AN (>85% IBW)(>85% IBW)
Bulimia Nervosa: subtypesBulimia Nervosa: subtypes
Purging typePurging type: : self-induced self-induced vomiting, laxative abuse, diuretic vomiting, laxative abuse, diuretic abuseabuse
Non-purging typeNon-purging type: : restricting, restricting, over-exercisingover-exercising
Eating Disorder NOSEating Disorder NOS
Subsyndromal AN or BNSubsyndromal AN or BN Current nomenclature for set of Current nomenclature for set of
criteria under investigation as “Binge criteria under investigation as “Binge Eating Disorder”Eating Disorder”
DSM IV Research Criteria:DSM IV Research Criteria:Binge Eating DisorderBinge Eating Disorder
Recurrent episodes of binge eating:Recurrent episodes of binge eating: large amount with subjective loss of controllarge amount with subjective loss of control
Associated with 3 or more: Associated with 3 or more: eating rapidly, eating until uncomfortably full, eating rapidly, eating until uncomfortably full, eating in private (embarrassment), eating when not eating in private (embarrassment), eating when not physically hungry, feeling guilty about eatingphysically hungry, feeling guilty about eating
Marked distress regarding binge Marked distress regarding binge eatingeating
Binge eating occurs, on average, at Binge eating occurs, on average, at least twice/week for six monthsleast twice/week for six months
Binge Eating DisorderBinge Eating Disorder Usually associated with overweight or Usually associated with overweight or
obesityobesity Approximately 30% of individuals Approximately 30% of individuals
presenting to medical weight loss presenting to medical weight loss programs meet criteria for BEDprograms meet criteria for BED
Obesity itself is not a psychiatric illness, Obesity itself is not a psychiatric illness, but 8% of overweight women and almost but 8% of overweight women and almost one third of those presenting for weight one third of those presenting for weight loss treatment meet criteria for BEDloss treatment meet criteria for BED
Often hard to diagnose – different from Often hard to diagnose – different from emotional eating /grazingemotional eating /grazing
Eating Disorders: EpidemiologyEating Disorders: Epidemiology
Abnormal eating can be found in all Abnormal eating can be found in all cultures but eating disorders are far more cultures but eating disorders are far more common in industrialized countriescommon in industrialized countries
EDs occur in all ethnic and EDs occur in all ethnic and socioeconomic groups in the US, socioeconomic groups in the US, although they are far more prevalent in although they are far more prevalent in the caucasian community and seem to the caucasian community and seem to have lowest rates in African American have lowest rates in African American communitycommunity
Anorexia Nervosa: how Anorexia Nervosa: how common?common?
AN incidence around 8/100,000 per AN incidence around 8/100,000 per yearyear
AN average prevalence among AN average prevalence among young females around 0.3%young females around 0.3%
About one third of AN population About one third of AN population enters mental health careenters mental health care
Increasing incidence in past century Increasing incidence in past century until 1970’s, particularly in 15-24 until 1970’s, particularly in 15-24 year old age group; debate about year old age group; debate about increase or decrease in rates since increase or decrease in rates since thenthen
Bulimia Nervosa: how Bulimia Nervosa: how common?common?
BN incidence 11-13/100,000 per BN incidence 11-13/100,000 per year in 1980s then decreasing year in 1980s then decreasing through 1990s to around through 1990s to around 6.6/100,000 per year in 20006.6/100,000 per year in 2000
BN prevalence around 1% of young BN prevalence around 1% of young femalesfemales
BN population enters mental BN population enters mental health treatment at very low ratehealth treatment at very low rate
ED NOS: how common?ED NOS: how common?
60% of the eating disorder cases in 60% of the eating disorder cases in outpatient settingsoutpatient settings
Unknown incidence, changing Unknown incidence, changing definitiondefinition
BED prevalence in US 2-5% and BED prevalence in US 2-5% and possibly occurring more frequently possibly occurring more frequently in AA community than in caucasian in AA community than in caucasian communitycommunity
All ages at risk, but . . .All ages at risk, but . . .
Eating disorders have onset most Eating disorders have onset most commonly in teen and young adult commonly in teen and young adult years, but may occur at other ages (BN years, but may occur at other ages (BN slightly later peak onset than AN)slightly later peak onset than AN)
<10% have onset prior to puberty<10% have onset prior to puberty
Eating Disorders: MalesEating Disorders: Males
Up to 10% of AN & BN patients are maleUp to 10% of AN & BN patients are male As many as 25% of BED patients are maleAs many as 25% of BED patients are male Males with eating disorders are more likely Males with eating disorders are more likely
to have once been overweight and more to have once been overweight and more likely to have used exercise for weight likely to have used exercise for weight controlcontrol
Males may be less likely to pursue Males may be less likely to pursue treatment for an eating disorder, but treatment for an eating disorder, but eating disorders are just as dangerous for eating disorders are just as dangerous for males as they are for femalesmales as they are for females
SurveySurvey
Dieted in the past year: 62% of high Dieted in the past year: 62% of high school girls,school girls, 40% of high school boys 40% of high school boys
Ever binged and purged: 13% of Ever binged and purged: 13% of adolescent girls, 7% of adolescent boysadolescent girls, 7% of adolescent boys
At least one third of junior high school At least one third of junior high school girls admit concerns about weightgirls admit concerns about weight
6% of 106% of 10thth grade boys have used grade boys have used laxativeslaxatives
Higher rates in those with alcoholismHigher rates in those with alcoholism Higher rates when not involved in athletics Or when Higher rates when not involved in athletics Or when
competing at elite levelcompeting at elite level
OutcomesOutcomes
AN: mortality 5-6% per decade of follow-up; AN: mortality 5-6% per decade of follow-up; SMR 9.6 in studies with 6-12 years of follow-up, SMR 9.6 in studies with 6-12 years of follow-up, 3.7 when 20-40 years of follow-up3.7 when 20-40 years of follow-up
Causes of death: suicide, starvation, cardiac Causes of death: suicide, starvation, cardiac eventsevents
Risk factors for death: BMI<13, body weight Risk factors for death: BMI<13, body weight <60%, low serum albumin<60%, low serum albumin
Suicides do not occur exclusively during Suicides do not occur exclusively during significant underweightsignificant underweight
Purging behaviors are worse prognostic sign Purging behaviors are worse prognostic sign than restricting alonethan restricting alone
CourseCourse
AN: half will have full recovery; up to 20% with AN: half will have full recovery; up to 20% with chronic unremitting coursechronic unremitting course
BN: 80% recovery if treated within first 5 years BN: 80% recovery if treated within first 5 years of illness; recovery falls to 20% by 15 years of of illness; recovery falls to 20% by 15 years of illnessillness
Much crossover between AN and BNMuch crossover between AN and BN Positive indicators for recovery: early onset, Positive indicators for recovery: early onset,
early treatment, higher weight at discharge or early treatment, higher weight at discharge or step-down, good social support, good step-down, good social support, good premorbid psychological functioningpremorbid psychological functioning
Psychiatric comorbidityPsychiatric comorbidity
More than a quarter of ED patients have a More than a quarter of ED patients have a comorbid mood disordercomorbid mood disorder
Comorbid anxiety disorder in up to half of AN Comorbid anxiety disorder in up to half of AN patients, up to 75% of BN patientspatients, up to 75% of BN patients
Comorbid alcohol abuse, drug abuse, Comorbid alcohol abuse, drug abuse, impulsivity common impulsivity common
>90% have at least one additional psychiatric >90% have at least one additional psychiatric diagnosis in lifetime, 50% at least one diagnosis in lifetime, 50% at least one concurrent with episode of ANconcurrent with episode of AN
Morbidity: Mental healthMorbidity: Mental health
Poor sleep and Depressive symptoms Poor sleep and Depressive symptoms secondary to starvation itselfsecondary to starvation itself
Antidepressants generally ineffective at low Antidepressants generally ineffective at low weightsweights
Cognitive impairment during underweight, Cognitive impairment during underweight, changes in brain volumechanges in brain volume
Increased anxiety during weight gain Increased anxiety during weight gain secondary to changing hormonal milieu and secondary to changing hormonal milieu and increasing serotoninincreasing serotonin
Adverse effects of major illness episode on Adverse effects of major illness episode on normal developmental trajectorynormal developmental trajectory
Morbidity: ReproductionMorbidity: Reproduction
Reduced fertility at low weightReduced fertility at low weight Higher rates of obstetric difficultiesHigher rates of obstetric difficulties Decreased intrauterine growth of babyDecreased intrauterine growth of baby
Morbidity: Bone healthMorbidity: Bone health Decrease in peak bone mineral densityDecrease in peak bone mineral density Calcium supplements less effective at low Calcium supplements less effective at low
weightweight Weight-bearing exercise helpful but cannot Weight-bearing exercise helpful but cannot
offset adverse effects of underweightoffset adverse effects of underweight Estrogen supplements alone do not preserve Estrogen supplements alone do not preserve
bone density in underweight premenopausal bone density in underweight premenopausal femalesfemales
Bisphosphonates teratogenic potential Bisphosphonates teratogenic potential unknown unknown
Morbidity: Body image, Self esteemMorbidity: Body image, Self esteem
Initial weight gain truncal. Degree of Initial weight gain truncal. Degree of redistribution variableredistribution variable
Lower rates of marriage and Lower rates of marriage and childbearingchildbearing
Decreased achievement relative to Decreased achievement relative to potentialpotential
What causes an eating disorder?What causes an eating disorder?
Multifactorial Multifactorial Strong evidence of genetic Strong evidence of genetic
component from twin studiescomponent from twin studiesBUTBUT
Higher incidence in industrialized Higher incidence in industrialized countries AND not everyone with a countries AND not everyone with a weight concern develops an eating weight concern develops an eating disorderdisorder
Genetic factorsGenetic factors
58-88% of risk for developing AN, and roughly 58-88% of risk for developing AN, and roughly same for BNsame for BN
Eating and Body-related behavioral and Eating and Body-related behavioral and attitudinal factors appear to have heritable attitudinal factors appear to have heritable componentcomponent
BMI highly heritable and independent of ED-BMI highly heritable and independent of ED-related heritable factorsrelated heritable factors
AN and Chromosome 1AN and Chromosome 1 BN and self-induced vomiting and Chromosome BN and self-induced vomiting and Chromosome
1010
Other factorsOther factors
Developmental eventsDevelopmental events Family dynamicsFamily dynamics Peer milieuPeer milieu Cultural influencesCultural influences
““Genetics loads the gun . . .Genetics loads the gun . . .Environment pulls the trigger”Environment pulls the trigger”
(C. Bulik)(C. Bulik)
The assessmentThe assessment
Ask About:Ask About:
Weight HistoryWeight History Highest and lowest adult weightsHighest and lowest adult weights Recent weight changesRecent weight changes Perceived “ideal” weightPerceived “ideal” weight
Eating Behaviors Eating Behaviors Attempts to restrict intake (diet pill use, Attempts to restrict intake (diet pill use,
skip meals, limit amounts or types of food, skip meals, limit amounts or types of food, counting fat/CHO grams, counting kcal)counting fat/CHO grams, counting kcal)
Binge Eating (objective vs subjective)Binge Eating (objective vs subjective)
Ask About:Ask About:
Attempts to “compensate” for intake Attempts to “compensate” for intake Self-induced vomiting (*ask about use of Self-induced vomiting (*ask about use of
Ipecac syrup)Ipecac syrup) Laxative abuseLaxative abuse Diuretic abuseDiuretic abuse Driven exerciseDriven exercise
Body ImageBody Image
Ask About:Ask About: Menstrual historyMenstrual history
Review of Systems Review of Systems (dizziness, fainting, (dizziness, fainting, weakness, fatigue)weakness, fatigue)
Psychiatric Symptoms Psychiatric Symptoms (depressed mood, (depressed mood, self-harm ideations, self-harm behaviors, self-harm ideations, self-harm behaviors, anxiety, neurovegetative symptoms)anxiety, neurovegetative symptoms)
Substance Use, past and currentSubstance Use, past and current
Medical assessmentMedical assessment
Physical Exam, review of systemsPhysical Exam, review of systems Medical history, weight historyMedical history, weight history Medication use, substance useMedication use, substance use Vital signs, laboratory testing, EKGVital signs, laboratory testing, EKG
Common Medical IssuesCommon Medical Issues
CardiovascularCardiovascular Orthostatic hypotension (starvation)Orthostatic hypotension (starvation) Bradycardia (starvation)Bradycardia (starvation) Prolonged QTc and T-wave abnormalities Prolonged QTc and T-wave abnormalities
on EKG (purging behaviors)on EKG (purging behaviors) Mitral valve prolapse (diminished muscle Mitral valve prolapse (diminished muscle
mass)mass) Cardiomyopathy (Ipecac)Cardiomyopathy (Ipecac)
Medical Issues (continued)Medical Issues (continued)
Cell countsCell counts Low WBC (starvation and stress)Low WBC (starvation and stress) Anemia (starvation)Anemia (starvation)
Fluid and electrolytesFluid and electrolytes Dehydration (starvation, purging)Dehydration (starvation, purging) Decreased albumin (starvation)Decreased albumin (starvation) Peripheral edema and effusions Peripheral edema and effusions
(starvation)(starvation) Electrolyte disturbances (purging)Electrolyte disturbances (purging)
Medical issues (continued)Medical issues (continued)
RenalRenal Acid-base disturbances (purging)Acid-base disturbances (purging) Impaired concentrating ability Impaired concentrating ability
BoneBone OsteopeniaOsteopenia OsteoporosisOsteoporosis
Medical Issues (continued)Medical Issues (continued)
EndocrineEndocrine Hypoglycemia (starvation)Hypoglycemia (starvation) Hypothermia (starvation)Hypothermia (starvation) Thyroid abnormalities (starvation, stress)Thyroid abnormalities (starvation, stress) Amenorrhea and decreased sex hormone Amenorrhea and decreased sex hormone
levels (starvation, stress)levels (starvation, stress)
Medical issues (continued)Medical issues (continued)
GastrointestinalGastrointestinal Bloating, nausea (starvation)Bloating, nausea (starvation) Elevated liver enzymes (starvation, Elevated liver enzymes (starvation,
refeeding)refeeding) Elevated cholesterol (starvation)Elevated cholesterol (starvation) Constipation and decreased motility Constipation and decreased motility
(starvation)(starvation) Esophageal tears (purging)Esophageal tears (purging)
Medical issues (continued)Medical issues (continued)
DermatologicDermatologic Hair loss (stress, starvation)Hair loss (stress, starvation) Dull hair (decreased fat)Dull hair (decreased fat) Lanugo hair (starvation)Lanugo hair (starvation) Dry skin (decreased fat)Dry skin (decreased fat) Calloused or scarred knuckles (purging)Calloused or scarred knuckles (purging) Acrocyanosis (starvation)Acrocyanosis (starvation)
Dental (purging)Dental (purging)
Other causes of weight loss . . .Other causes of weight loss . . .
Thyroid diseaseThyroid disease Adrenal diseaseAdrenal disease GI disease (motility problems, IBD, celiac GI disease (motility problems, IBD, celiac
disease)disease) MalignanciesMalignancies InfectionInfection . . . and other rare entities . . .. . . and other rare entities . . .
Nutrition needsNutrition needs Refeeding: Refeeding: start with 30-35 kcal/kg, then start with 30-35 kcal/kg, then
increase by around 300 kcal every three days to increase by around 300 kcal every three days to achieve gain of 1-2 kg per week as inpatient, achieve gain of 1-2 kg per week as inpatient, 0.5-1 kg per week as outpatient. (Diet 55-60% 0.5-1 kg per week as outpatient. (Diet 55-60% CHO, <30% fat, meet calculated protein needs)CHO, <30% fat, meet calculated protein needs)
Starved patients becomeStarved patients become hypermetabolic, hypermetabolic, often requiring 60-100 kcal/kg per day to gain often requiring 60-100 kcal/kg per day to gain and maintain.and maintain.
Hypermetabolic state may persist for 6-12 Hypermetabolic state may persist for 6-12 months after weight recoverymonths after weight recovery
Assessment done. Now what?Assessment done. Now what?
Indications for Inpatient Indications for Inpatient CareCareParameterParameter APAAPA AAPAAP% IBW% IBW < 75% definite < 75% definite
inpatientinpatient
< 85% highly < 85% highly structured structured
<75% or ongoing wt <75% or ongoing wt loss despite intensive loss despite intensive mgt mgt
Orthostatic Orthostatic hypotensionhypotension
> 20 bpm> 20 bpm
> 20 mm Hg> 20 mm Hg> 20 bpm> 20 bpm
> 10 mm Hg> 10 mm Hg
BradycardiaBradycardia < 40 bpm< 40 bpm
(in 40s for children)(in 40s for children)< 50 bpm day< 50 bpm day
< 45 bpm night< 45 bpm night
Blood Blood pressurepressure
< 90/60 mm Hg< 90/60 mm Hg
< 80/50 (children)< 80/50 (children)Systolic < 90 mm HgSystolic < 90 mm Hg
TemperatureTemperature < 97 deg< 97 deg <96 deg<96 deg
Body fat %Body fat % __________________ < 10%< 10%
Other Indications for Inpatient Other Indications for Inpatient CareCare
SyncopeSyncope Serum potassium < 3.2 mmol/LSerum potassium < 3.2 mmol/L Serum chloride < 88 mmol/LSerum chloride < 88 mmol/L Esophageal tearsEsophageal tears Cardiac arrhythmias, including prolonged QTc Cardiac arrhythmias, including prolonged QTc
intervalinterval Intractable vomitingIntractable vomiting HematemesisHematemesis Failure to respond to outpatient treatmentFailure to respond to outpatient treatment Severity of psychiatric comorbidities (Major Severity of psychiatric comorbidities (Major
depression, anxiety disorders, substance depression, anxiety disorders, substance abuse disorders)abuse disorders)
Indications for Partial Indications for Partial HospitalizationHospitalization
Individual does not require Individual does not require inpatient care but has not made inpatient care but has not made progress in less intensive treatment progress in less intensive treatment setting OR transitioning from setting OR transitioning from inpatient careinpatient care
Indications for outpatient Indications for outpatient carecare
Individual is above 75% IBW, medically Individual is above 75% IBW, medically stable, appropriate with self-care, and stable, appropriate with self-care, and motivated for treatmentmotivated for treatment
No adequate trial of outpatient care (a No adequate trial of outpatient care (a team including Family/Individual therapist, team including Family/Individual therapist, PCP, Psychiatrist and Nutritionist)PCP, Psychiatrist and Nutritionist)
Medical and psychiatric comorbidities are Medical and psychiatric comorbidities are stabilized or can be managed in an stabilized or can be managed in an outpatient setting.outpatient setting.
A word on medications . . .A word on medications . . .
Psychotropic MedicationPsychotropic Medication
Stay away fromStay away from StimulantsStimulants BuproprionBuproprion TCA’sTCA’s Megace/appetite stimulantsMegace/appetite stimulants
Nutrition remains the key Nutrition remains the key “medication”“medication”
Anorexia NervosaAnorexia Nervosa
Some evidence of lower relapse rates with Some evidence of lower relapse rates with use of SSRI’s once weight-recovereduse of SSRI’s once weight-recovered
SSRI’s are ineffective at low weights, but may SSRI’s are ineffective at low weights, but may begin to exert some effect once patient has begin to exert some effect once patient has progressed beyond 80% of IBWprogressed beyond 80% of IBW
Typical antipsychotics, lithium, Typical antipsychotics, lithium, anticonvulsants, opioid antagonists, appetite anticonvulsants, opioid antagonists, appetite stimulants do not appear to be effectivestimulants do not appear to be effective
Bulimia NervosaBulimia Nervosa
SSRI’s at higher doses seem to SSRI’s at higher doses seem to decrease binge/purge behaviors decrease binge/purge behaviors independent of their efficacy with regard independent of their efficacy with regard to depressive symptomsto depressive symptoms
Some data support decreased Some data support decreased binge/purge frequency with topiramate binge/purge frequency with topiramate but side effects are common, weight but side effects are common, weight loss commonloss common
Best Practices Treatment Best Practices Treatment GuidelinesGuidelines
American Psychiatric AssociationAmerican Psychiatric Associationhttp://www.psych.org/psych_pract/treatghttp://www.psych.org/psych_pract/treatg
American Academy of PediatricsAmerican Academy of Pediatrics NICE guidelines (UK)NICE guidelines (UK)
http://www.nice.org.ukhttp://www.nice.org.uk
ResourcesResources
www.nationaleatingdisorders.orgwww.nationaleatingdisorders.org www.aedweb.orgwww.aedweb.org www.edauk.comwww.edauk.com www.anad.orgwww.anad.org www.somethingfishy.orgwww.somethingfishy.org
UNC Hospitals ED program (919)966-UNC Hospitals ED program (919)966-70127012