Therapy in Anorexia

Therapies for the Inpatient Treatment of Anorexia nervosa

January 2005

Blymire

Penn State College of Medicine

 

Epidemiology:

-Females>Males

-Prevalence in 15-18 y/o females: 0.5%-1.0%

-Mid teen years are the most common age of onset

Comorbid conditions:

-Depression – 50% dual diagnosis

-Bulimia – 30-50% dual diagnosis

 

DSM IV Criteria for Anorexia Nervosa

1. Refusal to maintain body weight at or above a minimally normal weight for age and height (body weight <85%)
2. Intense fear of gaining weight or becoming fat, even though underweight
3. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
4. In postmenarcheal females, amenorrhea of at least 3 consecutive menstrual cycles

Specific types:

Restricting Type

Binge-Eating/Purging Type

 

Outcomes

-Outcome of adolescent eating disorders is relatively similar across cultures with regard to the main features of the disease.

-Approximately 76% of patients reach full recovery in a median time of 79 months, 10% reach partial recovery in 57 months and 14% maintain a chronic course.

-Mortality overall 5-18% (one follow-up study showed 6.8%) due to suicide, cardiac complications, electrolyte abnormalities, and completion in the course of eating disorders.

 

Treatment

-Anorexia patients spend a considerable proportion of their lifetime in treatment

-Research has shown the psychotherapy and behavioral therapy shows 3x weight gain as compared to a pharmacotherapy only group.

-Therefore, if therapy is more effective than pharmacotherapy, how do different methods of behavioral therapy vary?

 

Okamoto, A, et al. 2002. A behavior therapy program combined with liquid nutrition designed for anorexia nervosa. Psychiatry and Clinical Neurosciences 56:515-520

 

This study compared modified methods of behavior therapy in hospitalized anorexia nervosa patients and looked at total weight gain at time intervals (from 1 month after admission, for total period of hospitalization, and from admission to 6 months after discharge). They focused on three methods of behavior therapy:

 

1. Patient sets a target weight at admission and starts with a low-calorie diet in which calories are increased each week.     The patients start out with activity restriction and that is slowly lifted based on oral intake.
2. Patients undergo the therapy outlined in #1 with a token economy added.     A token is given for a certain amount of weight gain and the tokens can be turned in for some type of amusement or entertainment.
3. For the first week after admission, patients are evaluated for physical or mental changes induced by weight loss and educated about restoration of nutrition by oral feeding solutions. The patients are on normal diets with no activity restriction.     From week two to approximately week six, patients are placed on oral feeding solutions and activity restriction.     At this point, patients are slowly shifted to hospital meals and as their BMI begins to increase a target weight is set.     Also activity restrictions are slowly lifted in regards to how much weight gain is accomplished instead of actual intake like in numbers two and three. In fact this method provides for far more freedom than the other two methods including overnight passes from the hospital.

 

The outcome measured in this study is weight gain. The patients were 35 female consecutive in patients with anorexia (30 were restricting type and 5 were binge-eating/purging type). Seven patients were grouped in #1 and #2 and 21 patients were in #3. BMI was determined at admission, one month after admission, at discharge and six months after discharge.

 

They found that #3, at every temporal point, had the highest rate of increase in BMI as compared to the other methods. It was significantly higher as compared to #1 (p<0.05).

The authors feel that #3 worked the best in the first month after admission patients can regard the oral liquid nutrition not as normal food but as medicine and therefore be less anxious about food intake and still maintain motivation. For the total period of hospitalization, the authors feel that #3 allows patients to maintain motivation. After discharge, there were lower decreases in BMI possibly due to the higher increase in body weight attained in #3.

 

Now, what if drugs are added to the Behavioral therapy?

 

 

Attia, E., Haiman, C., Walsh, B.T., and Flater, S.R. 1998. Does fluoxetine augment the inpatient treatment of anorexia nervosa. American Journal of Psychiatry 155(4):548-551.

 

This study looked at adding fluoxetine to inpatient treatment. They felt the fluoxetine would be a good choice since patients with anorexia nervosa frequently exhibit mood disturbances and symptoms of OCD. This random, double-blinded study compared fluoxetine to placebo in 33 patients at 65% ideal body weight. Patients also received individual psychotherapy and group therapy. The outcome they measured was weight gain. They found that when compared to placebo, fluoxetine added no benefits in weight gain, even in patients that were depressed or with bulimic symptoms. The authors were not sure how to explain this. They felt that the sample size could have been too small even though they determined that the group had a power of 75% of detecting a statistically significant difference. It is interesting that later studies however, showed a significantly reduced rate of relapse in anorexia nervosa.

 

In this study, could it be possible that the fluoxetine has a lower efficacy in malnourished patients? Could nutritional factors play a role in efficacy of SSRI’s?

 

 

Barbarich, N.C. et al. 2004. Use of nutritional supplements to increase efficacy of fluoxetine in the treatment of anorexia nervosa. International Journal of Eating Disorders 3:10-15.

 

In this randomized double blind study, patients were assigned to either a group receiving daily dietary supplements of tryptophan, a multivitamin and fish oil capsules or a placebo group receiving starch and sunflower oil in capsules. The researchers chose tryptophan and the protein/carbohydrates combination in order to increase serotonin production and release, hopefully augmenting the fluoxetine affects. Study included 26 individuals, ten of which were restricting type, 6 restricting and purging only, and 10 binging and purging type. Overall, there was no significant difference between the supplemented group and the placebo group in terms of weight gain. In fact there was no difference in changes in anxiety, obsessive and compulsive symptoms or depressive symptoms.

The authors feel that the small sample size and a significant drop out rate limited this study. They do feel that this study suggests that the nutrition supplements are ineffective in increasing SSRI efficacy.

 

So does drug therapy have a part in initial inpatient treatment in regards to anorexia nervosa and weight gain?

 

At this point, there does not seem to be enough studies to support SSRI use in early inpatient treatment of anorexia nervosa. Research has shown that behavioral therapy is effective but does a drug/behavioral therapy exist?

 

References

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4^th ed. American Psychiatric Association, Washington, DC, 1994.

 

Attia, E., Haiman, C., Walsh, B.T., and Flater, S.R. 1998. Does fluoxetine augment the inpatient treatment of anorexia nervosa. American Journal of Psychiatry 155(4):548-551.

 

Barbarich, N.C. et al. 2004. Use of nutritional supplements to increase efficacy of fluoxetine in the treatment of anorexia nervosa. International Journal of Eating Disorders 3:10-15.

 

“Childhood Disorders” Psychiatry Clerkship Notes Packet for 2004-2005.

 

Emans, S.J. 2000. Eating disorders in adolescent girls. Pediatrics International 42:1-7.

 

Okamoto, A, et al. 2002. A behavior therapy program combined with liquid nutrition designed for anorexia nervosa. Psychiatry and Clinical Neurosciences 56:515-520.

 

Steinhausen, H.C. et al. 2000. A transcultural outcome study of adolescent eating disorders. Acta Psychiatrica Scandinavica 101:60-66.