DIAGNOSIS AND TREATMENT OF EATING DISORDERS
| PSYCHOPHARMACOLOGY FOR EATING DISORDERS —Joel Yager, MD, Professor and Vice Chair for Education
and Academic Affairs, University of New Mexico School of Medicine, Albuquerque; Professor Emeritus, Department
of Psychiatry and Behavioral Sciences, David Geffen School of Medicine at the University of California,
Los Angeles
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| Anorexia nervosa (AN): now considered as typical or atypical; in atypical form, patients recognize that their concept
of themselves as fat is erroneous; atypical form generally has better prognosis; new data suggest that amenorrhea
not always present and should not be considered necessary criterion in making diagnosis; some patients have
slight amount of bleeding or spotting, even though they do not ovulate; patients sort into prototypes based on combination
of Axis I and Axis II disorders; prototypes include being high functioning and perfectionistic, being constricted
and overcontrolled, and being emotionally dysregulated and undercontrolled
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| Eating disorder not otherwise specified (EDNOS): Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV) diagnostic category into which ≈50% of patients with eating disorders fall; includes
binge-eating disorder, which speaker thinks will have its own diagnostic category in DSM-V; controversial whether
EDNOS should be divided into “anorexia-like eating disorder” and “bulimia-like eating disorder”
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| Binge-eating disorder: shares episodic binge-eating qualities of bulimia nervosa (BN); individual eats until uncomfortably
full or eats large quantities when not hungry; as percentage of obesity in general population increases,
percentage of people with binge-eating disorder also increases
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| Epidemiology of eating disorders: National Comorbidity Study shows that ≈0.5% of American women have
AN, 1% to 2% have BN, and ≈2% have binge-eating disorder; however, “if you are treating women with depression,
PTSD (posttraumatic stress disorder), bipolar disorder, and everything else and you are not finding eating disorders,
you are probably not looking for them”; speaker suggests screening all women patients for eating disorders
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| Semistarvation and malnutrition: cause “all kinds of physiological effects”; if cortisone high and estrogen low,
calcium lost and osteopenia or osteoporosis may develop; in study, subjects with AN had 7 times more minor stress
fractures than control group; semistarvation and malnutrition can cause infertility; undernourishment can cause
premature delivery and low birth weight, and babies may have “their own developmental difficulties later on”
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| Bulimia nervosa: physical signs include chubby cheeks (due to hyperplasia of parotid glands), scarring on hands
and fingers (due to self-induced purging; “it’s kind of a clinical sign pathognomonic [for] an active purging
history”), erosion of dental enamel, dehydration, and resting bradycardia and hypotension
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| Comorbid conditions in eating disorders: 50% to 70% of women with eating disorders have major depression
or dysthymia; 5.7% to 12% have bipolar disorder; 10% to 13% with AN have obsessive-compulsive disorder;
≈30% have anxiety disorder; rates of substance abuse elevated, with highest rate in BN
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 | Childhood traits of obsessive-compulsive personality disorder: women with restrictive AN found to have high incidence
of perfectionism in childhood; those who are inflexible and rule-bound have 7 times greater risk for developing
AN
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| Other comorbid disorders: higher than expected rates of PTSD and dissociative problems; personality disorders in
40% to 70% of those with eating disorders
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| Prognosis: “it takes a long time to get better, even if you are going to get better”; ≈25% never get better; patients
who have AN at young age tend to “stay with anorexia nervosa for the rest of their lives”; people with AN tend to
have many major medical illnesses later on (suggesting that “4 or 5 yr of malnutrition as a teenager sets you up for
a variety of vulnerabilities later on”); mortality rate 12 times that for general population, 20% after 20 yr; people
with normal-weight bulimia generally do better
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| Binge-eating disorder: compulsive overeating; treatment directed at symptoms, not at obesity (“it’s much harder
to help people to lose weight than it is to [help them] stop being binge eaters”)
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| Treatment: consider medical and psychiatric symptoms; if treating somebody with eating disorder in ambulatory
setting, form working group that includes primary care physician (eg, pediatrician, family practitioner), psychiatrist,
psychologist or social worker, perhaps registered dietitian; all should have experience dealing with eating
disorders; since patients rarely respond to therapist who provides only one form of psychotherapy, so therapist
needs to be conversant with several forms of psychotherapy and be flexible in using them; “somebody in the
working group” has to see family; current guidelines suggest family-based therapy most effective, especially
with younger patients
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| Goals of treatment: for AN and BN, restoring healthy weight and menses; restoring or instituting healthy eating
patterns; dealing with physical complications; correcting thinking and associated psychologic problems; getting
family to work with therapist and patient; once patient has recovered, doing whatever possible to prevent relapse
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| Other considerations: intervene as early as possible; the greater the degree of initial weight loss, the greater the cognitive
impairment and the greater the amount of white and gray matter lost; white matter usually restored with recovery,
but gray matter not completely restored
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| Medications: AN—no randomized controlled trials and no drugs approved by Food and Drug Administration (FDA);
in study of hospitalized patients with AN, if hospital treatment program good, adding selective serotonin reuptake
inhibitor (SSRI) did not result in shorter hospital stay or in patient’s feeling better; open-label studies underway
with olanzapine and risperidone, but patients do not like side effects; BN—in trials with bupropion, too
many patients had seizures, and manufacturer withdrew indication for BN; some studies show good results with
60 to 80 mg of fluoxetine; 1 randomized controlled trial underway with sertraline (Zoloft); small trials show topiramate
may be useful if patient can tolerate side effects; binge-eating disorder—several studies show that SSRIs
useful; other studies show some hope for selective norepinephrine reuptake inhibitor (SNRI), venlafaxine (Effexor),
sibutramine, zonisamide, and topiramate
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| PSYCHOTHERAPY FOR EATING DISORDERS —Carol B. Peterson, PhD, LP, Research Associate and Assistant
Professor, Eating Disorders Research Program, Department of Psychiatry, University of Minnesota, Minneapolis,
Medical School
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| Impulsive and compulsive features of eating disorders: theories include impulsive and/or compulsive features
preceding eating disorders, being consequences of eating disorders, or some other factor leading to eating disorders
and impulsivity/compulsivity; once eating disorders and impulsivity/compulsivity develop, do they interact
with and affect each other?
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| Effects of semistarvation: study done during World War II to determine effects of semistarvation and how to refeed
prisoners of war who had undergone it; subjects were healthy volunteers who, on starvation diet, became depressed,
anhedonic, and lost interest in “pretty much anything”; became very ritualistic about eating and food preparation and
developed obsessive thoughts about them; their overall effect was similar to that of patients with eating disorders;
when allowed to refeed, many subjects engaged in binge eating
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| Impulsivity: defined as acting without thinking or without examining consequences of behavior; goal often gratification;
includes different components, including planning, motor activity, and attention; characterized as both
trait and set of behaviors
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| Eating-disorder symptoms that might be considered impulsive: binge eating; overeating; purging/compensatory behaviors
(eg, self-induced vomiting, misuse of laxatives and/or diuretics, excessive exercise); eating high-risk
foods; dietary restriction and fasting; inability to plan snacks and meals; chaotic eating patterns
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| Long-term outcome: over time, reduction in impulsivity symptoms correlates with reduction in eating-disorder
symptoms
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| Subtypes of AN: traditionally divided into restricting and binge-eating-and-purging subtypes, but recent data bring
subtypes into question; most individuals in restricting subtype eventually develop bulimic symptoms; recent prospective
studies have not found differences in comorbid symptoms and treatment outcome
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| Bulimia nervosa: impulsive features—multi-impulsive BN described as diagnostic subgroup; associated in some
studies with poorer outcomes; multi-impulsive BN co-occurs with drug and alcohol abuse, self-injurious behaviors,
suicide attempts, stealing, and/or sexual disinhibition; compulsive features—strong or irresistible impulses to perform
certain behavior, often done to prevent or to reduce anxiety; repetitive behaviors or mental acts that patient
feels driven to perform; compulsivity considered both trait and set of behaviors
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| Possible causes of eating disorders: risk factors—genetics; trauma; social influences (eg, thinness ideal); precipitating
factors—dieting; stressful life events or transitions; maintenance factors—biologic (perhaps serotonin); psychologic
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| Treatment: literature shows that treatment aimed at only eating disorders also produces improvement in mood,
anxiety, and impulsive and compulsive symptoms; impulsive measures usually predictive of treatment outcomes,
but compulsive measures not predictive; impulsivity tends to produce dropout
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| Treatment options: 1) do not treat impulsivity or compulsivity, but assume that treating eating disorder will result
in improvement in them; 2) target impulsivity/compulsivity in context of treatment, related to eating-disorder
symptoms or independent of them; 3) provide adjuvant treatment (eg, medications, psychotherapy) for impulsivity/compulsivity;
4) provide sequential treatment (usually targeting eating disorder first)
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| Empirically supported treatment for eating disorders
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| Cognitive behavioral therapy (CBT): rationale to modify thoughts and behaviors that cause and maintain eating-
disorder symptoms; based on cognitive model of eating-disorder symptoms, which says low self-esteem leads to
concerns about shape and weight, which leads to strict dieting, which in turn leads to binge eating and purging;
CBT typically starts with behavioral and nutritional rehabilitation and stimulus control, then targets cognitive aspects
and associated problems, and finishes with relapse prevention; involves identification of cues, stimuli, or
triggers (eg, driving home from school or work) associated with eating-disorder symptoms; encourages patient to
modify his or her response to stimuli through avoidance, response delay, and modification of thoughts that influence
feelings and behavior; impulsivity and compulsivity targeted through self-monitoring of symptoms and
cognitive restructuring
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| Interpersonal therapy (IPT): adapted from manual for treatment of depression; short-term, present-focused treatment
that targets changing relationships; comparable to CBT at follow-up for BN and binge-eating disorder (“less promising
for anorexia”); in stage 1, determine primary interpersonal problems that will become focus of treatment; in
stage 2, patient takes active role in trying to change relationships; stage 3 focuses on wrapping up
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| Family-based therapy (FBT) for AN: rationale that parents competent and should be responsible for refeeding their
adolescent/child; works best with younger patients (<18 yr of age) who have been ill for shorter duration (<3 yr);
preliminary evidence suggests that it also helps adolescents with BN; attempts to engage whole family in helping
child with AN
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| Dialectical behavior therapy (DBT): based on manual for treating borderline personality disorder; rationale that individuals
with eating disorders struggle with affect regulation, and affect contributes to onset and maintenance of
eating-disorder symptoms; helps impulsivity and compulsivity
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| Conclusions: eating disorders involve complex pattern of behavioral and psychologic symptoms that include impulsive
and compulsive features; presence of these traits does not necessarily imply that patient has personality disorder;
impulsivity/compulsivity may be etiologic risk factor, but also often persists (to lesser degree) when eating-
disorder symptoms improve; some symptoms, especially compulsivity, may be direct result of semistarvation
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Educational Objectives
| The goal of this program is to educate the listener about the diagnosis and treatment of eating disorders. After hearing
and assimilating this program, the clinician will be better able to:
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| 1. Use the third revision of the American Psychiatric Association’s guidelines for the treatment of eating disorders.
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| 2. Describe some of the controversies surrounding the eating-disorder criteria in the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Revision (DSM-IV).
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| 3. Discuss the pharmacologic treatment of eating disorders.
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| 4. Explain the impulsive and compulsive features of eating disorders.
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| 5. Discuss several psychotherapeutic treatments for eating disorders.
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Discussed on This Program
Fluoxetine hydrochloride [Prozac, Sarafem]
Olanzapine [Zyprexa]
Risperidone [Risperdal]
Suggested Reading
American Psychiatric Association: Treatment of patients with eating disorders, third edition. American Psychiatric
Association. Am J Psychiatry 163(7 Suppl):4, 2006; Binford RB, Peterson CB et al: Coping strategies in
bulimia nervosa treatment: impact on outcome in group cognitive-behavioral therapy. J Consult Clin Psychol
73:1089, 2005; Franko DL et al: Pregnancy complications and neonatal outcomes in women with eating disorders.
Am J Psychiatry 158:1461, 2001; Garfinkel PE et al: Bulimia nervosa in a Canadian community sample: prevalence
and comparison of subgroups. Am J Psychiatry 152:1052, 1995; Garfinkel PE et al: Should amenorrhoea be
necessary for the diagnosis of anorexia nervosa? Evidence from a Canadian community sample. Br J Psychiatry
168:500, 1996; Grilo CM: Recent research of relationships among eating disorders and personality disorders. Curr
Psychiatry Rep 4:18, 2002; Katzman DK, Yager J, et al: From prevention to prognosis: clinical research update
on adolescent eating disorders. Pediatr Res 47:709, 2000; Lock J et al: Treatment Manual for Anorexia Nervosa: A
Family-Based Approach. New York: Guilford Press, 2005; Lock J, le Grange D: Help Your Teenager Beat an
Eating Disorder. New York: Guilford Press, 2005; Masheb RM, Grilo CM: On the relation of flexible and rigid
control of eating to body mass index and overeating in patients with binge eating disorder. Int J Eat Disord 31:82,
2002; Mitchell JE, Peterson CB et al: Combining pharmacotherapy and psychotherapy in the treatment of patients
with eating disorders. Psychiatr Clin North Am 24:315, 2001; Mussell MP, Peterson CB et al: Utilization
of empirically supported psychotherapy treatments for individuals with eating disorders: A survey of psychologists.
Int J Eat Disord 27:230, 2000; Peterson CB et al: Subtypes of binge eating disorder based on psychiatric history.
Int J Eat Disord 38:273, 2005; Ricca V et al: Psychopathological and clinical features of outpatients with an eating
disorder not otherwise specified. Eat Weight Disord 6:157, 2001; Sunday SR, Peterson CB et al: Differences in
DSM-III-R and DSM-IV diagnoses in eating disorder patients. Compr Psychiatry 42:448, 2001; Tozzi F et al: Price
Foundation Collaborative Group. Features associated with laxative abuse in individuals with eating disorders. Psychosom
Med 68:470, 2006; Westen D, Harnden-Fischer J: Personality profiles in eating disorders: rethinking
the distinction between axis I and axis II. Am J Psychiatry 158:547, 2001; Wilson GT et al: Cognitive-behavioral
therapy for bulimia nervosa: time course and mechanisms of change. J Consult Clin Psychol 70:267, 2002; Yager J,
Andersen AE: Clinical practice. Anorexia nervosa. N Engl J Med 353:1481, 2005; Yager J: Weighty perspectives:
contemporary challenges in obesity and eating disorders. Am J Psychiatry 157:851, 2000; Yucel B, Yager J
et al: Eating disorders and celiac disease: a case report. Int J Eat Disord 39:530, 2006; Yucel B, Yager J et al:
Weight fluctuations during early refeeding period in anorexia nervosa: case reports. Int J Eat Disord 37:175, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
the faculty reported nothing to disclose.
Dr. Yager was recorded at the 11th Annual Psychopharmacology Update, held February 16-19, 2006, in Las Vegas,
NV, and sponsored by the American Psychiatric Association and the Nevada Psychiatric Association. Dr. Peterson
was recorded at 7th Annual Psychiatry Review: The Impulsive-Compulsive Spectrum, held September 26-26, 2006, in
Minneapolis, MN, and sponsored by the University of Minnesota Medical School. The Audio-Digest Foundation
thanks the speakers and the sponsors for their cooperation in the production of this program.
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