Anorexia Nervosa Medication
- Author: Bettina E Bernstein, DO; Chief Editor: Caroly Pataki, MD more...
Medication SummaryAntidepressive agentsAtypical antipsychoticsGastrointestinal prokinetic agents
The use of medication in individuals with anorexia nervosa is limited to the treatment of medical complications. To treat osteopenia and to prevent further bone loss, daily dietary intake of calcium 1000-1500 mg and vitamin D 400 IU are recommended. Estrogen replacement (ie, oral contraceptives) has also been recommended for the treatment of osteopenia, although the benefits and minimal effective dose is being explored. Bisphosphonate therapy can be effective, but the patient should be closely monitored for osteonecrosis of the mandible.
Evidence regarding the efficacy of medication treatment for eating disorders has tended to be weak or moderate, especially as side effects tend to limit long-term compliance compared with the time devoted to psychotherapeutic treatments. However, randomized, controlled trials have shown benefits from the use of medication in combination with cognitive behavioral therapy (CBT).[6, 7, 123]
Fluoxetine was found to be generally helpful in patients with anorexia nervosa who had been stabilized with weight restoration. Psychotherapy with adjunctive low-dose olanzapine may be useful for anorexia nervosa during inpatient treatment, especially in the context of anxiety, obsessive eating-related ruminations, and treatment resistance due to failure to engage. Higher-dose fluoxetine and/or topiramate may be helpful in bulimia nervosa. At this time, however, medication for weight loss in bulimia nervosa is not recommended, due to significant adverse effects such as pulmonary hypertension and heart failure.[6, 7]
In a meta-analysis of 8 studies involving 221 patients with anorexia nervosa, antipsychotics failed to show efficacy for body weight or other anorexia-related outcomes.
Pharmacotherapy should not be the only line of treatment and should be used with caution in suspected bipolar disorder, but it may be helpful for depression. Most patients who recover from anorexia nervosa will have been treated with a multidisciplinary approach that includes medication, psychotherapy, nutritional counseling, and frequent medical evaluations.
Antidepressive and neuroleptic agents, although not reported to be effective, have a limited use in patients who have adequate nutrition and mood changes associated with anorexia nervosa. Prolongation of the QT interval is a contraindication to tricyclic antidepressants because a prolonged QT may increase the risk of ventricular tachycardia and death.
SSRIs and SNRIs
Selective serotonin reuptake inhibitors (SSRIs) have been shown to be beneficial in patients with bulimia nervosa but not anorexia. However, since many patients with anorexia have concurrent mood disorders, medication may be of benefit.
In patients with anorexia nervosa who have attained 85% of their expected weight, the SSRI fluoxetine has been used to stabilize recovery. Zinc and cyproheptadine have not been useful. SSRIs and serotonin norepinephrine reuptake inhibitors (SNRIs) may be more helpful for addressing concurrent obsessive-compulsive issues and, owing to their relative neutral effect on weight, may be more easily accepted by the patient.
SSRIs are greatly preferred over the other classes of antidepressants. Because the adverse effect profile of SSRIs is less prominent, improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered in the treatment of a child or adolescent with a mood disorder.
Precautions in the pediatric population
Use appropriate caution when considering treatment with SSRIs in the pediatric population. In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine, which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.
In October 2003, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality (ideation and attempts) in pediatric patients being treated with antidepressant medications for major depressive disorder and other conditions. The FDA asked, however, that additional studies be performed because suicidality occurred in treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.
In 2005, the FDA proposed that manufacturers change antidepressant labeling by adding a black-box warning regarding the increased suicidality risk in children and adolescents who use antidepressants. The labeling change also emphasized the need for appropriate monitoring and patient awareness via medication guides. Two years later, the FDA also recommended updates on the black-box labeling of antidepressants regarding increased risk of suicidality in young adults aged 18-24 during initial treatment (generally the first 1-2 months).
A cohort study looked at suicide risk for youths younger than 24 years in the context of use of SSRIs and SNRIs and the current “Black Box” warning regarding increased risk of suicidal ideation in this population. This retrospective cohort study included 36,842 children aged 6-18 years enrolled in Tennessee Medicaid from 1995-2006 who were new users of 1 of the antidepressant medications of interest (defined as filling no prescriptions for antidepressants in the preceding 365 days). It found that there was increased risk for suicide attempts among users of multiple antidepressants concomitantly; however, there was no evidence that risk of suicide attempts increased when one medication was prescribed and the adjusted rate of suicide attempts did not differ significantly among current users of SSRI and SNRI antidepressants compared with current users of fluoxetine.
The current evidence does not support an increased risk of suicide in patients with obsessive-compulsive disorder or other anxiety disorders who are treated with SSRIs.
The atypical antipsychotics (eg, olanzapine, quetiapine, risperidone) have shown some benefit in the treatment of anorexia nervosa. This is thought likely to be from their effects on depression, anxiety, and core eating disordered psychopathology. However, there are significant safety concerns surrounding these drugs due to the high likelihood of cardiac conduction abnormalities in patients with anorexia.[125, 128]
Part of the pathophysiology of anorexia nervosa is a delay in gastric emptying, which can perpetuate the disorder by limiting the quantity of food that can be eaten. Although a study of cisapride (Propulsid) did not show gastric-emptying enhancement, participants reported a greater improvement in subjective symptoms during a meal.
In 2000, however, cisapride use in patients with anorexia nervosa or bulimia was discouraged after cisapride was found to be associated with serious cardiac events (ie, serious arrhythmias associated with prolonged QTc) and the risk of cardiovascular-related events in patients with eating disorders.
Electrolyte repletion is necessary in patients with profound malnutrition, dehydration, and purging behaviors. Repletion may be done orally or parenterally, depending on the patient’s clinical state.
Calcium moderates nerve and muscle performance by regulating the action potential excitation threshold. It also improves bone density.
Potassium is essential for the transmission of nerve impulses, contraction of cardiac muscle, maintenance of intracellular tonicity, skeletal and smooth muscle contraction, and maintenance of normal renal function. Gradual potassium depletion occurs via renal excretion or gastrointestinal loss or because of low intake. Depletion usually results from diuretic therapy, primary or secondary hyperaldosteronism, diabetic ketoacidosis, severe diarrhea (if associated with vomiting), or inadequate replacement during prolonged parenteral nutrition.
Potassium depletion sufficient to cause 1 mEq/L drop in the serum potassium level requires a loss of approximately 100-200 mEq of potassium from the total body store.
Calcium gluconate moderates nerve and muscle performance and facilitates normal cardiac function. It can initially be given intravenously, and then calcium levels can be maintained with a high-calcium diet. Some patients require oral calcium supplementation. The 10% intravenous (IV) solution provides 100 mg/mL of calcium gluconate, equaling 9 mg/mL (0.46 mEq/mL) of elemental calcium. One 10-mL ampule contains 93 mg of elemental calcium.
For severe hypophosphatemia (< 1 mg/dL), parenteral preparations of phosphate should be used for repletion. IV preparations are available as sodium or potassium phosphate (K2PO4). Response to IV serum phosphorus supplementation is highly variable and is associated with hyperphosphatemia and hypocalcemia. The rate of infusion and choice of initial dosage should be based on the severity of hypophosphatemia and the presence of symptoms. Serum phosphate and calcium should be monitored closely.
For less severe hypophosphatemia (1-2 mg/dL), oral phosphate salt preparations can be used. Oral preparations are available as sodium or potassium phosphate in capsule or liquid form. Neutra-Phos packets each contain 250 mg of phosphorus; tablets contain 250, 125.6, or 114 mg. Liquid preparations are available as 250 mg/75 mL.
Vitamins, Fat Soluble
Vitamins are used to meet necessary dietary requirements. They are utilized in metabolic pathways, as well as in deoxyribonucleic acid (DNA) and protein synthesis.
This is a vitamin D-2 analogue that is converted in the liver to an active intermediate and then further converted to its most active form in the kidneys. It stimulates the absorption of calcium and phosphate from the small intestine and promotes the release of calcium from bone into blood. Because it is a precursor, a significant delay between dose administration and effect exists. The liver must be intact for the intermediate to be formed (calcidiol, 25-hydroxy vitamin D). Many drugs may affect this step.
Ergocalciferol is stored in fat, so when there is a lack of fat (due to weight loss), the potential exists for overdose of ergocalciferol. It has lipid storage, so overdoses may cause prolonged hypercalcemia.
Ergocalciferol is used as a replacement therapy. To measure of its efficacy, assess the serum calcium concentration.
These agents have been reported to reduce binge eating, vomiting, and depression and to improve eating habits, although their impact on body dissatisfaction remains unclear.
Fluoxetine selectively inhibits presynaptic serotonin reuptake, with minimal or no effect on the reuptake of norepinephrine or dopamine. It may cause more adverse gastrointestinal effects than other currently available SSRIs, which is the reason it is not recommended as a first choice.
Fluoxetine can be administered as a liquid or a capsule and can be given in single or divided doses. The presence of food does not appreciably alter levels of the medication. It may take up to 4-6 weeks to achieve steady-state levels of the medication because it has a long half-life (72 h). The long half-life is both an advantage and a drawback. If fluoxetine works well, an occasional missed dose is not a problem; if fluoxetine-related problems occur, however, eliminating all active metabolites takes a long time.
The choice to use fluoxetine depends on adverse effects and drug interactions. Adverse effects of SSRIs seem to be quite idiosyncratic; thus, relatively few reasons exist to prefer one over another at this point if dosing is started at a conservative level and advanced as tolerated.
Fluoxetine is indicated for the treatment of binge eating and self-induced vomiting in patients with moderate to severe bulimia nervosa. The drug's antidepressant, anti–obsessive-compulsive, and antibulimic actions are presumed to be linked to inhibition of the central nervous system's uptake of serotonin.
Miller KK, Grinspoon SK, Ciampa J, Hier J, Herzog D, Klibanski A. Medical findings in outpatients with anorexia nervosa. Arch Intern Med. 2005 Mar 14. 165(5):561-6. [Medline].
Cinkajzlova A, Lacinova Z, Klouckova J, Kavalkova P, Trachta P, Kosak M, et al. Angiopoietin-like protein 6 in patients with obesity, type 2 diabetes mellitus, and anorexia nervosa: The influence of very low-calorie diet, bariatric surgery, and partial realimentation. Endocr Res. 2016 May 2. 1-9. [Medline].
Eisler I, Simic M, Russell GF, Dare C. A randomised controlled treatment trial of two forms of family therapy in adolescent anorexia nervosa: a five-year follow-up. J Child Psychol Psychiatry. 2007 Jun. 48(6):552-60. [Medline].
Morris J, Twaddle S. Anorexia nervosa. BMJ. 2007 Apr 28. 334(7599):894-8. [Medline].
Waller G. Recent advances in psychological therapies for eating disorders. F1000Res. 2016. 5:[Medline].
Flament MF, Bissada H, Spettigue W. Evidence-based pharmacotherapy of eating disorders. Int J Neuropsychopharmacol. 2011 Mar 18. 1-19. [Medline].
Hay PJ, Claudino AM. Clinical psychopharmacology of eating disorders: a research update. Int J Neuropsychopharmacol. 2011 Mar 25. 1-14. [Medline].
Katzman DK, Peebles R, Sawyer SM, Lock J, Le Grange D. The role of the pediatrician in family-based treatment for adolescent eating disorders: opportunities and challenges. J Adolesc Health. 2013 Oct. 53(4):433-40. [Medline].
Kaplan H, Sadock B. Fleischer GR, Ludwig S, eds. Synopsis of Psychiatry. 8th ed. Williams and Wilkins; 1998. 720-727.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 5th ed. Washington, DC: APA Press; 2013.
Elran-Barak R, Accurso EC, Goldschmidt AB, Sztainer M, Byrne C, Le Grange D. Eating patterns in youth with restricting and binge eating/purging type anorexia nervosa. Int J Eat Disord. 2014 Apr 29. [Medline].
Forman S. Eating Disorders: epidemiology, pathogenesis, and clinical features. Up to Date [online]. 2005:[Full Text].
Hoek HW, van Hoeken D. Review of the prevalence and incidence of eating disorders. Int J Eat Disord. 2003 Dec. 34(4):383-96. [Medline].
Treasure J, Claudino AM, Zucker N. Eating disorders. Lancet. 2010 Feb 13. 375(9714):583-93. [Medline].
APA. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: APA; 1994.
Swanson SA, Crow SJ, Le Grange D, Swendsen J, Merikangas KR. Prevalence and correlates of eating disorders in adolescents: results from the national comorbidity survey replication adolescent supplement. Arch Gen Psychiatry. 2011 Jul. 68(7):714-23. [Medline].
Arun CP. Drive for leanness, anorexia nervosa, and overactivity: the missing link. Ann N Y Acad Sci. 2008 Dec. 1148:526-9. [Medline].
Facchini M, Sala L, Malfatto G, Bragato R, Redaelli G, Invitti C. Low-K+ dependent QT prolongation and risk for ventricular arrhythmia in anorexia nervosa. Int J Cardiol. 2006 Jan 13. 106(2):170-6. [Medline].
Golden NH. Eating disorders in adolescence: what is the role of hormone replacement therapy?. Curr Opin Obstet Gynecol. 2007 Oct. 19(5):434-9. [Medline].
Taylor C, Lamparello B, Kruczek K, Anderson EJ, Hubbard J, Misra M. Validation of a food frequency questionnaire for determining calcium and vitamin D intake by adolescent girls with anorexia nervosa. J Am Diet Assoc. 2009 Mar. 109(3):479-85, 485.e1-3. [Medline].
Lilenfeld LR, Kaye WH, Greeno CG, et al. A controlled family study of anorexia nervosa and bulimia nervosa: psychiatric disorders in first-degree relatives and effects of proband comorbidity. Arch Gen Psychiatry. 1998 Jul. 55(7):603-10. [Medline].
Ammaniti M, Lucarelli L, Cimino S, D'Olimpio F, Chatoor I. Maternal psychopathology and child risk factors in infantile anorexia. Int J Eat Disord. 2010 Apr. 43(3):233-40. [Medline].
Button E, Aldridge S. Season of birth and eating disorders: patterns across diagnoses in a specialized eating disorders service. Int J Eat Disord. 2007 Jul. 40(5):468-71. [Medline].
Sokol MS, Carroll AK, Heebink DM, Hoffman-Rieken KM, Goudge CS, Ebers DD. Anorexia nervosa in identical triplets. CNS Spectr. 2009 Mar. 14(3):156-62. [Medline].
Nilsson EW, Gillberg C, Råstam M. Familial factors in anorexia nervosa: a community-based study. Compr Psychiatry. 1998 Nov-Dec. 39(6):392-9. [Medline].
Trace SE, Baker JH, Peñas-Lledó E, Bulik CM. The genetics of eating disorders. Annu Rev Clin Psychol. 2013. 9:589-620. [Medline].
Steiger H, Richardson J, Schmitz N, et al. Association of trait-defined, eating-disorder sub-phenotypes with (biallelic and triallelic) 5HTTLPR variations. J Psychiatr Res. 2009 Sep. 43(13):1086-94. [Medline].
Wade TD, Gillespie N, Martin NG. A comparison of early family life events amongst monozygotic twin women with lifetime anorexia nervosa, bulimia nervosa, or major depression. Int J Eat Disord. 2007 Sep 14. 40(8):679-686. [Medline].
Wade TD, Treloar SA, Heath AC, Martin NG. An examination of the overlap between genetic and environmental risk factors for intentional weight loss and overeating. Int J Eat Disord. 2009 Sep. 42(6):492-7. [Medline]. [Full Text].
Grice DE, Halmi KA, Fichter MM, et al. Evidence for a susceptibility gene for anorexia nervosa on chromosome 1. Am J Hum Genet. 2002 Mar. 70(3):787-92. [Medline].
Stergioti E, Deligeoroglou E, Economou E, Tsitsika A, Dimopoulos KD, Daponte A, et al. Gene receptor polymorphism as a risk factor for BMD deterioration in adolescent girls with anorexia nervosa. Gynecol Endocrinol. 2013 Jul. 29(7):716-9. [Medline].
Bosanac P, Norman T, Burrows G, Beumont P. Serotonergic and dopaminergic systems in anorexia nervosa: a role for atypical antipsychotics?. Aust N Z J Psychiatry. 2005 Mar. 39(3):146-53. [Medline].
Fetissov SO, Harro J, Jaanisk M, et al. Autoantibodies against neuropeptides are associated with psychological traits in eating disorders. Proc Natl Acad Sci U S A. 2005 Oct 11. 102(41):14865-70. [Medline].
Galle J, Kirsch S, Kaufman M. Anorexia nervosa in a patient with congenital adrenal hyperplasia. J Pediatr Endocrinol Metab. 2013. 26(1-2):167-72. [Medline].
Toulany A, Katzman DK, Kaufman M, Hiraki LT, Silverman ED. Chicken or the Egg: Anorexia Nervosa and Systemic Lupus Erythematosus in Children and Adolescents. Pediatrics. 2014 Jan 6. [Medline].
Mehler PS, Gray MC, Schulte M. Medical complications of anorexia nervosa. J Womens Health. 1997 Oct. 6(5):533-41. [Medline].
Preti A, Girolamo Gd, Vilagut G, Alonso J, Graaf Rd, Bruffaerts R, et al. The epidemiology of eating disorders in six European countries: results of the ESEMeD-WMH project. J Psychiatr Res. 2009 Sep. 43(14):1125-32. [Medline].
Steinhausen HC. Outcome of eating disorders. Child Adolesc Psychiatr Clin N Am. 2009 Jan. 18(1):225-42. [Medline].
Wallier J, Vibert S, Berthoz S, Huas C, Hubert T, Godart N. Dropout from inpatient treatment for anorexia nervosa: critical review of the literature. Int J Eat Disord. 2009 Nov. 42(7):636-47. [Medline].
National Institute of Mental Health. Collaborative Psychiatric Epidemiology Surveys (CPES). Collaborative Psychiatric Epidemiology Surveys. Available at http://www.icpsr.umich.edu/CPES/. Accessed: October 30, 2007.
Fernandes NH, Crow SJ, Thuras P, Peterson CB. Characteristics of black treatment seekers for eating disorders. Int J Eat Disord. 2010 Apr. 43(3):282-5. [Medline].
Raevuori A, Hoek HW, Susser E, Kaprio J, Rissanen A, Keski-Rahkonen A. Epidemiology of anorexia nervosa in men: a nationwide study of Finnish twins. PLoS ONE. 2009. 4(2):e4402. [Medline].
Feldman MB, Meyer IH. Childhood abuse and eating disorders in gay and bisexual men. Int J Eat Disord. 2007 Jul. 40(5):418-23. [Medline].
Isomaa R, Isomaa AL, Marttunen M, Kaltiala-Heino R, Björkqvist K. The prevalence, incidence and development of eating disorders in Finnish adolescents-a two-step 3-year follow-up study. Eur Eat Disord Rev. 2009 May. 17(3):199-207. [Medline].
Lavelle JM. Adolescent emergencies. Fleischer GR, Ludwig S, eds. Textbook of Pediatric Emergency Medicine. Philadelphia: Lippincott Williams & Wilkins; 1993. 166(12): 1503-1526.
Wentz E, Gillberg IC, Anckarsäter H, Gillberg C, Rastam M. Adolescent-onset anorexia nervosa: 18-year outcome. Br J Psychiatry. 2009 Feb. 194(2):168-74. [Medline].
Speranza M, Loas G, Wallier J, Corcos M. Predictive value of alexithymia in patients with eating disorders: A 3-year prospective study. J Psychosom Res. 2007 Oct. 63(4):365-71. [Medline].
Steinhausen HC. The outcome of anorexia nervosa in the 20th century. Am J Psychiatry. 2002 Aug. 159(8):1284-93. [Medline].
Franko DL, Keel PK, Dorer DJ, Blais MA, Delinsky SS, Eddy KT. What predicts suicide attempts in women with eating disorders?. Psychol Med. 2004 Jul. 34(5):843-53. [Medline].
Holm-Denoma JM, Witte TK, Gordon KH, et al. Deaths by suicide among individuals with anorexia as arbiters between competing explanations of the anorexia-suicide link. J Affect Disord. 2008 Apr. 107(1-3):231-6. [Medline].
Halmi KA. Anorexia nervosa: an increasing problem in children and adolescents. Dialogues Clin Neurosci. 2009. 11(1):100-3. [Medline].
Crow SJ, Peterson CB, Swanson SA, Raymond NC, Specker S, Eckert ED, et al. Increased mortality in bulimia nervosa and other eating disorders. Am J Psychiatry. 2009 Dec. 166(12):1342-6. [Medline].
Witte TK, Merrill KA, Stellrecht NE, Bernert RA, Hollar DL, Schatschneider C, et al. "Impulsive" youth suicide attempters are not necessarily all that impulsive. J Affect Disord. 2008 Apr. 107(1-3):107-16. [Medline].
Woolrich RA, Cooper MJ, Turner HM. Metacognition in patients with anorexia nervosa, dieting and non-dieting women: a preliminary study. Eur Eat Disord Rev. 2008 Jan. 16(1):11-20. [Medline].
Modan-Moses D, Yaroslavsky A, Kochavi B, Toledano A, Segev S, Balawi F, et al. Linear growth and final height characteristics in adolescent females with anorexia nervosa. PLoS One. 2012. 7(9):e45504. [Medline]. [Full Text].
Kaplan AS, Walsh BT, Olmsted M, Attia E, Carter JC, Devlin MJ, et al. The slippery slope: prediction of successful weight maintenance in anorexia nervosa. Psychol Med. 2009 Jun. 39(6):1037-45. [Medline].
Sylvester CJ, Forman SF. Clinical practice guidelines for treating restrictive eating disorder patients during medical hospitalization. Curr Opin Pediatr. 2008 Aug. 20(4):390-7. [Medline].
Forman SF, Grodin LF, Graham DA, Sylvester CJ, Rosen DS, Kapphahn CJ, et al. An eleven site national quality improvement evaluation of adolescent medicine-based eating disorder programs: predictors of weight outcomes at one year and risk adjustment analyses. J Adolesc Health. 2011 Dec. 49(6):594-600. [Medline].
Kaye WH, Bulik CM, Thornton L, Barbarich N, Masters K. Comorbidity of anxiety disorders with anorexia and bulimia nervosa. Am J Psychiatry. 2004 Dec. 161(12):2215-21. [Medline].
Jordan J, Joyce PR, Carter FA, McIntosh VV, Luty SE, McKenzie JM, et al. The Yale-Brown-Cornell eating disorder scale in women with anorexia nervosa: what is it measuring?. Int J Eat Disord. 2009 Apr. 42(3):267-74. [Medline].
Bryant-Waugh R, Knibbs J, Fosson A, Kaminski Z, Lask B. Long term follow up of patients with early onset anorexia nervosa. Arch Dis Child. 1988 Jan. 63(1):5-9. [Medline].
Björkenstam E, Björkenstam C, Holm H, Gerdin B, Ekselius L. Excess cause-specific mortality in in-patient-treated individuals with personality disorder: 25-year nationwide population-based study. Br J Psychiatry. 2015 Oct. 207 (4):339-45. [Medline].
Kask J, Ekselius L, Brandt L, Kollia N, Ekbom A, Papadopoulos FC. Mortality in Women With Anorexia Nervosa: The Role of Comorbid Psychiatric Disorders. Psychosom Med. 2016 Apr 29. [Medline].
Treasure J, Nazar BP. Interventions for the Carers of Patients With Eating Disorders. Curr Psychiatry Rep. 2016 Feb. 18 (2):16. [Medline].
Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality Rates in Patients With Anorexia Nervosa and Other Eating Disorders: A Meta-analysis of 36 Studies. Arch Gen Psychiatry. 2011 Jul. 68(7):724-31. [Medline].
Støving RK, Hangaard J, Hansen-Nord M, Hagen C. A review of endocrine changes in anorexia nervosa. J Psychiatr Res. 1999 Mar-Apr. 33(2):139-52. [Medline].
Matzkin V, Slobodianik N, Pallaro A, Bello M, Geissler C. Risk factors for cardiovascular disease in patients with anorexia nervosa. Int J Psychiatr Nurs Res. 2007 Sep. 13(1):1531-45. [Medline].
Vázquez M, Olivares JL, Fleta J, Lacambra I, González M. [Cardiac disorders in young women with anorexia nervosa]. Rev Esp Cardiol. 2003 Jul. 56(7):669-73. [Medline].
Morse JL, Safdar B. Acute tension pneumothorax and tension pneumoperitoneum in a patient with anorexia nervosa. J Emerg Med. 2010 Apr. 38(3):e13-6. [Medline].
Verhoef PA, Rampal A. Unique challenges for appropriate management of a 16-year-old girl with superior mesenteric artery syndrome as a result of anorexia nervosa: a case report. J Med Case Rep. 2009 Nov 16. 3:127. [Medline]. [Full Text].
Nicholls DE, Lynn R, Viner RM. Childhood eating disorders: British national surveillance study. Br J Psychiatry. 2011 Apr. 198(4):295-301. [Medline].
Price C, Schmidt MA, Adam EJ, Lacey H. Parotid gland enlargement in eating disorders: an insensitive sign?. Eat Weight Disord. 2008 Dec. 13(4):e79-83. [Medline].
Sterling WM, Golden NH, Jacobson MS, Ornstein RM, Hertz SM. Metabolic assessment of menstruating and nonmenstruating normal weight adolescents. Int J Eat Disord. 2009 Nov. 42(7):658-63. [Medline].
Wade TD, Frayne A, Edwards SA, Robertson T, Gilchrist P. Motivational change in an inpatient anorexia nervosa population and implications for treatment. Aust N Z J Psychiatry. 2009 Mar. 43(3):235-43. [Medline].
Ziora K, Ziora D, Oswiecimska J, et al. Spirometric parameters in malnourished girls with anorexia nervosa. J Physiol Pharmacol. 2008 Dec. 59 suppl 6:801-7. [Medline].
Birgegård A, Björck C, Norring C, Sohlberg S, Clinton D. Anorexic self-control and bulimic self-hate: differential outcome prediction from initial self-image. Int J Eat Disord. 2009 Sep. 42(6):522-30. [Medline].
Hrabosky JI, Cash TF, Veale D, et al. Multidimensional body image comparisons among patients with eating disorders, body dysmorphic disorder, and clinical controls: a multisite study. Body Image. 2009 Jun. 6(3):155-63. [Medline].
Kawai K, Yamanaka T, Yamashita S, et al. Somatic and psychological factors related to the body mass index of patients with anorexia nervosa. Eat Weight Disord. 2008 Dec. 13(4):198-204. [Medline].
Jordan J, Joyce PR, Carter FA, et al. Specific and nonspecific comorbidity in anorexia nervosa. Int J Eat Disord. 2008 Jan. 41(1):47-56. [Medline].
Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ. 1999 Dec 4. 319(7223):1467-8. [Medline].
Altinyazar V, Kiylioglu N, Salkin G. Anorexia nervosa and Wernicke Korsakoff's syndrome: atypical presentation by acute psychosis. Int J Eat Disord. 2010 Dec. 43(8):766-9. [Medline].
Kreipe RE, Birndorf SA. Eating disorders in adolescents and young adults. Med Clin North Am. 2000 Jul. 84(4):1027-49, viii-ix. [Medline].
Nicholls D, Viner R. Eating disorders and weight problems. BMJ. 2005 Apr 23. 330(7497):950-3. [Medline].
Jones ER, Morgan JF, Arcelus J. Managing physical risk in anorexia nervosa. Adv Psychiatrist Treat. 2013. 19:201-2.
Puxley F, Midtsund M, Iosif A, Lask B. PANDAS anorexia nervosa--endangered, extinct or nonexistent?. Int J Eat Disord. 2008 Jan. 41(1):15-21. [Medline].
Roberts CM, Martin-Clavijo A, Winston AP, Dharmagunawardena B, Gach JE. Malnutrition and a rash: think zinc. Clin Exp Dermatol. 2007 Nov. 32(6):654-7. [Medline].
Toulany A, Katzman DK, Kaufman M, Hiraki LT, Silverman ED. Chicken or the egg: anorexia nervosa and systemic lupus erythematosus in children and adolescents. Pediatrics. 2014 Feb. 133(2):e447-50. [Medline].
Ward L, Tricco AC, Phuong P, et al. Bisphosphonate therapy for children and adolescents with secondary osteoporosis. Cochrane Database Syst Rev. 2007 Oct 17. CD005324. [Medline].
Coxson HO, Chan IH, Mayo JR, Hlynsky J, Nakano Y, Birmingham CL. Early emphysema in patients with anorexia nervosa. Am J Respir Crit Care Med. 2004 Oct 1. 170(7):748-52. [Medline].
Lesinskiene S, Barkus A, Ranceva N, Dembinskas A. A meta-analysis of heart rate and QT interval alteration in anorexia nervosa. World J Biol Psychiatry. 2007 Apr 5. 1-6. [Medline].
Gowers SG. Management of eating disorders in children and adolescents. Arch Dis Child. 2008 Apr. 93(4):331-4. [Medline].
Muscari M. Effective management of adolescents with anorexia and bulimia. J Psychosoc Nurs Ment Health Serv. 2002 Feb. 40(2):22-31. [Medline].
Schwartz BI, Mansbach JM, Marion JG, Katzman DK, Forman SF. Variations in admission practices for adolescents with anorexia nervosa: a North American sample. J Adolesc Health. 2008 Nov. 43(5):425-31. [Medline].
Golden NH. Variability in admission practices for teens hospitalized with anorexia nervosa: a call for evidence-based outcome studies. J Adolesc Health. 2008 Nov. 43(5):417-8. [Medline].
Divasta AD, Feldman HA, Beck TJ, Leboff MS, Gordon CM. Does hormone replacement normalize bone geometry in adolescents with anorexia nervosa?. J Bone Miner Res. 2014 Jan. 29(1):151-7. [Medline]. [Full Text].
Herpertz-Dahlmann B, Salbach-Andrae H. Overview of treatment modalities in adolescent anorexia nervosa. Child Adolesc Psychiatr Clin N Am. 2009 Jan. 18(1):131-45. [Medline].
Tchanturia K, Larsson E, Brown A. Benefits of group cognitive remediation therapy in anorexia nervosa: case series. Neuropsychiatr. 2016 Mar. 30 (1):42-49. [Medline].
Higgins J, Hagman J, Pan Z, MacLean P. Increased physical activity not decreased energy intake is associated with inpatient medical treatment for anorexia nervosa in adolescent females. PLoS One. 2013. 8(4):e61559. [Medline]. [Full Text].
Rio A, Whelan K, Goff L, Reidlinger DP, Smeeton N. Occurrence of refeeding syndrome in adults started on artificial nutrition support: prospective cohort study. BMJ Open. 2013 Jan 11. 3(1):[Medline]. [Full Text].
Rigaud D, Brondel L, Poupard AT, Talonneau I, Brun JM. A randomized trial on the efficacy of a 2-month tube feeding regimen in anorexia nervosa: A 1-year follow-up study. Clin Nutr. 2007 Aug. 26(4):421-9. [Medline].
Krantz MJ, Mehler PS. Resting tachycardia, a warning sign in anorexia nervosa: case report. BMC Cardiovasc Disord. 2004 Jul 16. 4:10. [Medline].
Jagielska G, Tomaszewicz-Libudzic EC, Brzozowska A. Pellagra: a rare complication of anorexia nervosa. Eur Child Adolesc Psychiatry. 2007 Oct. 16(7):417-20. [Medline].
Garber AK, Michihata N, Hetnal K, Shafer MA, Moscicki AB. A prospective examination of weight gain in hospitalized adolescents with anorexia nervosa on a recommended refeeding protocol. J Adolesc Health. 2012 Jan. 50(1):24-9. [Medline].
Kyriacou O, Treasure J, Schmidt U. Expressed emotion in eating disorders assessed via self-report: an examination of factors associated with expressed emotion in carers of people with anorexia nervosa in comparison to control families. Int J Eat Disord. 2008 Jan. 41(1):37-46. [Medline].
Lock J, Le Grange D, Agras WS, Moye A, Bryson SW, Jo B. Randomized clinical trial comparing family-based treatment with adolescent-focused individual therapy for adolescents with anorexia nervosa. Arch Gen Psychiatry. 2010 Oct. 67(10):1025-32. [Medline].
Fisher CA, Hetrick SE, Rushford N. Family therapy for anorexia nervosa. Cochrane Database Syst Rev. 2010. 4:CD004780. [Medline].
Bergh C, Brodin U, Lindberg G, Sodersten P. Randomized controlled trial of a treatment for anorexia and bulimia nervosa. Proc Natl Acad Sci U S A. 2002 Jul 9. 99(14):9486-91. [Medline].
Lock J, Fitzpatrick KK. Anorexia nervosa. Clin Evid (Online). 2009 Mar 10. 2009:[Medline].
Harper K, Richter NL, Gorey KM. Group work with female survivors of childhood sexual abuse: evidence of poorer outcomes among those with eating disorders. Eat Behav. 2009 Jan. 10(1):45-8. [Medline].
Wild B, Friederich HC, Gross G, Teufel M, Herzog W, Giel KE, et al. The ANTOP study: focal psychodynamic psychotherapy, cognitive-behavioural therapy, and treatment-as-usual in outpatients with anorexia nervosa--a randomized controlled trial. Trials. 2009 Apr 23. 10:23. [Medline].
Bowers WA, Ansher LS. The effectiveness of cognitive behavioral therapy on changing eating disorder symptoms and psychopathology of 32 anorexia nervosa patients at hospital discharge and one year follow-up. Ann Clin Psychiatry. 2008 Apr-Jun. 20(2):79-86. [Medline].
McIntosh VV, Jordan J, Carter FA, et al. Three psychotherapies for anorexia nervosa: a randomized, controlled trial. Am J Psychiatry. 2005 Apr. 162(4):741-7. [Medline].
Geist R, Heinmaa M, Stephens D, et al. Comparison of family therapy and family group psychoeducation in adolescents with anorexia nervosa. Can J Psychiatry. 2000 Mar. 45(2):173-8. [Medline].
Ehrlich S, Burghardt R, Schneider N, Broecker-Preuss M, Weiss D, Merle JV, et al. The role of leptin and cortisol in hyperactivity in patients with acute and weight-recovered anorexia nervosa. Prog Neuropsychopharmacol Biol Psychiatry. 2009 Jun 15. 33(4):658-662. [Medline].
Thien V, Thomas A, Markin D, Birmingham CL. Pilot study of a graded exercise program for the treatment of anorexia nervosa. Int J Eat Disord. 2000 Jul. 28(1):101-6. [Medline].
Davenport L. New Eating Disorder Guidelines Released. Medscape Medical News. Available at http://www.medscape.com/viewarticle/835980. Accessed: December 6, 2014.
Hay P, Chinn D, Forbes D, Madden S, Newton R, Sugenor L, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders. Aust N Z J Psychiatry. 2014 Nov. 48(11):977-1008. [Medline].
Reinblatt SP, Redgrave GW, Guarda AS. Medication management of pediatric eating disorders. Int Rev Psychiatry. 2008 Apr. 20(2):183-8. [Medline].
Kishi T, Kafantaris V, Sunday S, Sheridan EM, Correll CU. Are antipsychotics effective for the treatment of anorexia nervosa? Results from a systematic review and meta-analysis. J Clin Psychiatry. 2012 Jun. 73(6):e757-66. [Medline].
Wildes JE, Marcus MD, Gaskill JA, Ringham R. Depressive and manic-hypomanic spectrum psychopathology in patients with anorexia nervosa. Compr Psychiatry. 2007 Sep-Oct. 48(5):413-8. [Medline].
Ramoz N, Versini A, Gorwood P. Eating disorders: an overview of treatment responses and the potential impact of vulnerability genes and endophenotypes. Expert Opin Pharmacother. 2007 Sep. 8(13):2029-44. [Medline].
McKnight RF, Park RJ. Atypical antipsychotics and anorexia nervosa: a review. Eur Eat Disord Rev. 2010 Jan. 18(1):10-21. [Medline].
Szmukler GI, Young GP, Miller G, Lichtenstein M, Binns DS. A controlled trial of cisapride in anorexia nervosa. Int J Eat Disord. 1995 May. 17(4):347-57. [Medline].
Tchanturia K, Doris E, Mountford V, Fleming C. Cognitive Remediation and Emotion Skills Training (CREST) for anorexia nervosa in individual format: self-reported outcomes. BMC Psychiatry. 2015 Mar 20. 15:53. [Medline].
Attia E, Kaplan AS, Walsh BT, Gershkovich M, Yilmaz Z, Musante D, et al. Olanzapine versus placebo for out-patients with anorexia nervosa. Psychol Med. 2011 Oct. 41 (10):2177-82. [Medline].