eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Eating Disorder: Anorexia: Treatment & Medication

Author: Bettina E Bernstein, DO, Assistant Professor, Department of Psychiatry, Philadelphia College of Osteopathic Medicine; Private Practice at the Wynnewood House, Consultant to Child Guidance Resource Centers, Early Elementary Education Program
Contributor Information and Disclosures

Updated: Mar 31, 2008

Treatment

Medical Care

The medical modality is geared toward correcting and preventing the complications of anorexia nervosa.

  • Monitoring of weight, vital signs, and serum electrolyte levels is important.
  • Weight gain is a primary goal of treatment. Weight gain should not be excessive because rapid refeeding can lead to excessive bloating, edema, and, rarely, congestive heart failure (CHF).
  • Outpatient treatment should only be done with very close monitoring, such as weekly weight measurement wearing only a gown.
  • Family therapy should only be performed conjointly if the level of expressed emotion is not excessive;21 simultaneous sessions can be more productive because if patients feel intense negative emotions from their families they are more likely to be noncompliant with treatment.
  • Tube feeding often must be initiated on an inpatient basis when the patient's weight is less than or at 85% of expected weight because outpatient refeeding can be too uncomfortable and the weight gain can be too rapid for the patient to tolerate, sabotaging treatment.
  • Prolongation of the QT interval is a contraindication for the use of tricyclic antidepressants because a prolonged QT may increase the risk of ventricular tachycardia and death.
  • No treatment is needed for the euthyroid sick syndrome.
  • Estrogen has no established effect on bone density in patients with anorexia nervosa, and vitamin supplementation with calcium should be started.
  • Those at risk medically or psychiatrically require inpatient treatment. Indications for inpatient treatment include the following:
    • Low weight (£ 85% of expected weight) or rapid weight loss
    • Lack of any weight gain
    • Significant edema
    • Severe electrolyte imbalance (life-threatening risks created by sodium and potassium derangements)
    • Temperature less than 36 º C
    • Pulse less than 45 beats per minute
    • Altered mental status or other signs of severe malnutrition
    • Cardiac disturbances or other acute medical disorders
    • Psychosis or a high risk of suicide
    • Symptoms refractory to outpatient treatment
  • Individuals with anorexia nervosa may respond best to family therapy. Psychodynamic psychotherapy in combination with behavioral strategies is indispensable. Psychopharmacologic therapy is generally not helpful, although fluoxetine may stabilize recovery in patients who have already attained 85% of their weight.

Consultations

The approach to the treatment of individuals with anorexia nervosa is multidisciplinary. Consultations with specialists in adolescent medicine, nutrition, psychiatry or behavioral-developmental pediatrics, and psychology may be required.

Various psychological therapies have proven helpful in treating patients with anorexia nervosa, including the following:22,23,24

  • Individual therapy (insight-oriented)
  • Cognitive analytic therapy
  • Cognitive behavior therapy
  • Interpersonal therapy
  • Motivational enhancement therapy
  • Dynamically informed therapies
  • Group therapy
  • Family therapy
  • Conjoint therapy
  • Separated family therapy
  • Multifamily groups
  • Relatives and caregiver support groups

Tube refeeding does not impair efficacy of any psychological therapies.25

Diet

Nutrition is an important part of the treatment for the individual with anorexia nervosa. A nutritionist or dietitian should be an integral part of the treatment plan because the well-recognized refeeding syndrome can occur during the early stages of refeeding the patient with anorexia. This syndrome encompasses cardiovascular collapse; starvation-induced hypophosphatemia; and dangerous fluctuations in potassium, sodium, and magnesium levels.

  • According to Becker at al in 1999, for adequate weight gain, the patient or family requires some "education on nutrition, adjustment of caloric and nutritional intake, and limitations on exercise and other modifications of behavior. Enteral or parenteral nutrition is reserved for patients with severe undernutrition that has been refractory to treatment by these methods."26
  • In the moderate stage of anorexia nervosa, in addition to the above recommendations, providing structure to daily activities is necessary. This includes eating 3 meals a day. Also, parents should ensure that healthy food is available, but the patient should assume all responsibility for eating.
  • In 1997, Mehler et al proposed the following strategies to avoid the refeeding syndrome to avoid pitfalls during the refeeding period:8
    • Identify patients at risk.
    • Measure serum electrolyte levels and correct abnormalities before refeeding.
    • Obtain serum chemistry values every 3 days for the first 7 days and then weekly during the rest of refeeding.
    • Attempt to increase daily caloric intake slowly by 200-300 kcal every 3-5 days until sustained weight gain of 1-2 pounds per week is achieved.
    • Monitor the patient carefully for development of tachycardia27 or edema.
  • Monitor for pellagra and administer niacin supplementation if needed.28

Activity

Limited physical activity (eg, sports, exercise classes) is recommended. By limiting activity, energy expenditure is limited, thus assuring a balanced weight. Limitation of activity may also motivate the patient to maintain healthy eating habits in order to ensure a rapid return to favorite activities. Note that the disadvantage of curtailing activity is the removal of the patient's coping mechanism to deal with stress.

  • Anorexia nervosa is based on caloric restriction and increased caloric expenditure that leads to excess exercise to control weight. Previous studies have described the use of exercise programs for hospitalized inpatients in which exercise was exchanged for weight gain and compliance. However, no guidelines were set forth in terms of type, intensity, and duration of exercise.
  • A study by Thein et al (2000) looked at a standard program designed for outpatient use, graduated in type of exercise, duration, and level of activity.29 Without structure, patients could be exercising in potentially harmful ways and at very high intensities. This study showed that both the exercise and the control groups increased in body mass index (BMI) and body fat percentage. However, quality of life was increased in the exercise group, whereas the control group showed a decrease in all aspects of quality-of-life measures, although the difference was not statistically significant.

Medication

The use of medication for individuals with anorexia nervosa is limited to the treatment of medical complications. To treat osteopenia and to prevent further bone loss, dietary calcium (1000-1500 mg/d) and vitamin D (400 IU) are recommended. Estrogen replacement in the form of oral contraceptives has also been recommended for the treatment of osteopenia, although the benefits and minimal effective dose have not been established.

In anorexia nervosa, bone density is compromised, which can lead to an increase in fractures and early osteoporosis. The intake of calcium and other macronutrients that normally strengthen bone decreases because of poor nutrition. Studies of dehydroepiandrosterone (DHEA) using 50 mg, 100 mg, and 200 mg have reported a decrease in bone resorption, an increase in bone formation markers, and a possible association with resumption of menses (53%).30

The antiosteolytic and anabolic effects of DHEA have been noted to be secondary to the androgenic effects on bone mass and not secondary to the estrogenic effects, as was previously thought. Potential adverse effects include mild acne; decreases in cholesterol, high-density lipoprotein (HDL) and sex hormone binding globulin (SHBG) levels; insulin resistance, and hirsutism.

Limitations of the study by Gordon et al included the small size, a question of compliance, and the self-reporting of activity levels and nutritional intake; no response relationship between the doses of 50 mg, 100 mg, or 200 mg was clear.30

Pharmacotherapy is generally not effective. In patients with anorexia nervosa who have already attained 85% of their expected weight, fluoxetine has been used to stabilize recovery. Zinc and cyproheptadine have not been useful.

Antidepressive and neuroleptic agents, although not reported to be effective, have a limited use in patients who have mood changes associated with anorexia nervosa. Their use is limited in patients with inadequate nutrition.

Selective serotonin reuptake inhibitors (SSRIs) are greatly preferred over the other classes of antidepressants.31 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.

Physicians are advised to be aware of the following information and 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 (Prozac), 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 in pediatric patients being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.
  • However, a recent study of more than 65,000 children and adults treated for depression between 1992 and 2002 by the Group Health Cooperative in Seattle found that suicide risk declines, not rises, with the use of antidepressants.32 This is the largest study to date to address this issue.
  • Currently, evidence does not support an increased risk of suicide in patients with obsessive-compulsive disorder (OCD) and other anxiety disorders who are treated with SSRIs.

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. A study of cisapride (Propulsid) to improve gastric emptying did not show enhancement, but the patients did report a greater improvement in subjective symptoms during a meal.33 However, in 2000, cisapride use in patients with anorexia nervosa or bulimia was advised against because of serious cardiac events associated with the drug (ie, serious arrhythmias associated with prolonged QTc) and the risk of cardiovascular-related events in patients with eating disorders.

More on Eating Disorder: Anorexia

Overview: Eating Disorder: Anorexia
Differential Diagnoses & Workup: Eating Disorder: Anorexia
Treatment & Medication: Eating Disorder: Anorexia
Follow-up: Eating Disorder: Anorexia
References
Further Reading
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References

  1. Slupik RI. Managing adolescents with eating disorders. Int J Fertil Womens Med. May-Jun 1999;44(3):125-30. [Medline].

  2. 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. Oct 11 2005;102(41):14865-70. [Medline].

  3. APA. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: APA; 1994.

  4. Feldman MB, Meyer IH. Childhood abuse and eating disorders in gay and bisexual men. Int J Eat Disord. Jul 2007;40(5):418-23. [Medline].

  5. National Institute of Mental Health. National Comorbidity Survey (NCS) and National Comorbidity Survey Replication (NCS-R). Collaborative Psychiatric Epidemiology Surveys. Available at http://www.icpsr.umich.edu/CPES/. Accessed October 30, 2007.

  6. Button E, Aldridge S. Season of birth and eating disorders: patterns across diagnoses in a specialized eating disorders service. Int J Eat Disord. Jul 2007;40(5):468-71. [Medline].

  7. Grice DE, Halmi KA, Fichter MM, et al. Evidence for a susceptibility gene for anorexia nervosa on chromosome 1. Am J Hum Genet. Mar 2002;70(3):787-92. [Medline].

  8. Mehler PS, Gray MC, Schulte M. Medical complications of anorexia nervosa. J Womens Health. Oct 1997;6(5):533-41. [Medline].

  9. Rooney B, McClelland L, Crisp AH, Sedgwick PM. The incidence and prevalence of anorexia nervosa in three suburban health districts in south west London, U.K. Int J Eat Disord. Dec 1995;18(4):299-307. [Medline].

  10. 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. Oct 2007;63(4):365-71. [Medline].

  11. 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. Jan 1988;63(1):5-9. [Medline].

  12. Jordan J, Joyce PR, Carter FA, et al. Specific and nonspecific comorbidity in anorexia nervosa. Int J Eat Disord. Jan 2008;41(1):47-56. [Medline].

  13. 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. Apr 5 2007;1-6. [Medline].

  14. Franko DL, Keel PK, Dorer DJ, Blais MA, Delinsky SS, Eddy KT. What predicts suicide attempts in women with eating disorders?. Psychol Med. Jul 2004;34(5):843-53. [Medline].

  15. 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. Apr 2008;107(1-3):231-6. [Medline].

  16. 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. Jul 1998;55(7):603-10. [Medline].

  17. Kreipe RE, Birndorf SA. Eating disorders in adolescents and young adults. Med Clin North Am. Jul 2000;84(4):1027-49, viii-ix. [Medline].

  18. Puxley F, Midtsund M, Iosif A, Lask B. PANDAS anorexia nervosa--endangered, extinct or nonexistent?. Int J Eat Disord. Jan 2008;41(1):15-21. [Medline].

  19. Roberts CM, Martin-Clavijo A, Winston AP, Dharmagunawardena B, Gach JE. Malnutrition and a rash: think zinc. Clin Exp Dermatol. Nov 2007;32(6):654-7. [Medline].

  20. Nicholls D, Viner R. Eating disorders and weight problems. BMJ. Apr 23 2005;330(7497):950-3. [Medline].

  21. 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. Jan 2008;41(1):37-46. [Medline].

  22. Morris J, Twaddle S. Anorexia nervosa. BMJ. Apr 28 2007;334(7599):894-8. [Medline].

  23. 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. Jun 2007;48(6):552-60. [Medline].

  24. Rosenblum J, Forman S. Evidence-based treatment of eating disorders. Curr Opin Pediatr. Aug 2002;14(4):379-83. [Medline].

  25. 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. Aug 2007;26(4):421-9. [Medline].

  26. Becker AE, Grinspoon SK, Klibanski A, Herzog DB. Eating disorders. N Engl J Med. Apr 8 1999;340(14):1092-8. [Medline].

  27. Krantz MJ, Mehler PS. Resting tachycardia, a warning sign in anorexia nervosa: case report. BMC Cardiovasc Disord. Jul 16 2004;4:10. [Medline].

  28. Jagielska G, Tomaszewicz-Libudzic EC, Brzozowska A. Pellagra: a rare complication of anorexia nervosa. Eur Child Adolesc Psychiatry. Oct 2007;16(7):417-20. [Medline].

  29. 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. Jul 2000;28(1):101-6. [Medline].

  30. Gordon CM, Grace E, Emans SJ, et al. Changes in bone turnover markers and menstrual function after short-term oral DHEA in young women with anorexia nervosa. J Bone Miner Res. Jan 1999;14(1):136-45. [Medline].

  31. 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. Sep 2007;8(13):2029-44. [Medline].

  32. Simon GE, Savarino J, Operskalski B, Wang PS. Suicide risk during antidepressant treatment. Am J Psychiatry. Jan 2006;163(1):41-7. [Medline]. [Full Text].

  33. Szmukler GI, Young GP, Miller G, Lichtenstein M, Binns DS. A controlled trial of cisapride in anorexia nervosa. Int J Eat Disord. May 1995;17(4):347-57. [Medline].

  34. 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. Jul 9 2002;99(14):9486-91. [Medline].

  35. McIntosh VV, Jordan J, Carter FA, et al. Three psychotherapies for anorexia nervosa: a randomized, controlled trial. Am J Psychiatry. Apr 2005;162(4):741-7. [Medline].

  36. Geist R, Heinmaa M, Stephens D, et al. Comparison of family therapy and family group psychoeducation in adolescents with anorexia nervosa. Can J Psychiatry. Mar 2000;45(2):173-8. [Medline].

  37. Robin AL, Siegel PT, Moye A. Family versus individual therapy for anorexia: impact on family conflict. Int J Eat Disord. May 1995;17(4):313-22. [Medline].

  38. 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. Sep 2007;13(1):1531-45. [Medline].

  39. 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. Jan 13 2006;106(2):170-6. [Medline].

  40. Golden NH. Eating disorders in adolescence: what is the role of hormone replacement therapy?. Curr Opin Obstet Gynecol. Oct 2007;19(5):434-9. [Medline].

  41. Woolrich RA, Cooper MJ, Turner HM. Metacognition in patients with anorexia nervosa, dieting and non-dieting women: a preliminary study. Eur Eat Disord Rev. Sep 22 2007;[Medline].

  42. Gowers SG. Management of eating disorders in children and adolescents. Arch Dis Child. Apr 2008;93(4):331-4. [Medline].

  43. Muscari M. Effective management of adolescents with anorexia and bulimia. J Psychosoc Nurs Ment Health Serv. Feb 2002;40(2):22-31. [Medline].

  44. Witte TK, Merrill KA, Stellrecht NE, Bernert RA, Hollar DL, Schatschneider C. "Impulsive" youth suicide attempters are not necessarily all that impulsive. J Affect Disord. Sep 3 2007;[Medline].

  45. Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ. Dec 4 1999;319(7223):1467-8. [Medline].

  46. Steiner H, Lock J. Anorexia nervosa and bulimia nervosa in children and adolescents: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. Apr 1998;37(4):352-9. [Medline].

  47. Steinhausen HC. Outcome of anorexia nervosa in the younger patient. J Child Psychol Psychiatry. Mar 1997;38(3):271-6. [Medline].

  48. Tan JO, Hope T, Stewart A, Fitzpatrick R. Control and compulsory treatment in anorexia nervosa: the views of patients and parents. Int J Law Psychiatry. Nov-Dec 2003;26(6):627-45. [Medline].

  49. Tchanturia K, Davies H, Campbell IC. Cognitive remediation therapy for patients with anorexia nervosa: preliminary findings. Ann Gen Psychiatry. 2007;6:14. [Medline].

  50. 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. Sep 14 2007;40(8):679-686. [Medline].

  51. [Best Evidence] Ward L, Tricco A, Phuong P, Cranney A, Barrowman N, Gaboury I. Bisphosphonate therapy for children and adolescents with secondary osteoporosis. Cochrane Database Syst Rev. 2007;(4):CD005324. [Medline].

  52. Wildes JE, Marcus MD, Gaskill JA, Ringham R. Depressive and manic-hypomanic spectrum psychopathology in patients with anorexia nervosa. Compr Psychiatry. Sep-Oct 2007;48(5):413-8. [Medline].

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Further Reading

The SCOFF questionnaire is a screening tool for eating disorders. One point is awarded for every positive reply. A score greater than 2 indicates likely anorexia nervosa or bulimia. The questionnaire is as follows: 45

  • Do you make yourself Sick because you feel uncomfortably full?
  • Do you worry you have lost Control over how much you eat?
  • Have you lost more than One stone in a 3-month period?
  • Do you believe yourself to be Fat when others say you are too thin?
  • Would you say that Food dominates your life?

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Keywords

anorexia, anorexia nervosa, eating disorders, excessive weight loss, anorexiant, anorexic, anorectic, diminished appetite, aversion to food, psychiatric disorder, fear of weight gain, dieting, amenorrhea, constipation, hypotension, bradycardia, hypothermia, dry skin, hypercarotenemia, lanugo body hair, acrocyanosis, breast atrophy, mitral valve prolapse, hypokalemic hypochloremic metabolic alkalosis, acidosis, leukopenia, thrombocytopenia, dehydration, distorted body image, congestive heart failure, CHF, edema, psychosis

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Contributor Information and Disclosures

Author

Bettina E Bernstein, DO, Assistant Professor, Department of Psychiatry, Philadelphia College of Osteopathic Medicine; Private Practice at the Wynnewood House, Consultant to Child Guidance Resource Centers, Early Elementary Education Program
Bettina E Bernstein, DO is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry and American Psychiatric Association
Disclosure: Nothing to disclose.

Medical Editor

Angelo P Giardino, MD, PhD, Clinical Associate Professor, Department of Pediatrics, Baylor College of Medicine; Medical Director, Texas Children's Health Plan, Inc
Angelo P Giardino, MD, PhD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and American Professional Society on the Abuse of Children
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting; Pfizer Honoraria Consulting

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry, Department of Psychiatry and Biobehavioral Sciences, Division Chair of Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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