Treatment of Eating Disorders
Transcript Treatment of Eating Disorders
Dr Jackie Hoare
Liaison Psychiatry GSH
is an illness characterised by extreme concern about
with serious disturbances in eating behavior
leading to a self-imposed starvation state
Severe weight loss.
Body image becomes the predominant measure of selfworth
denial of the seriousness of the illness.
(a) refusal to maintain weight within the normal
range for height and age
(b) fear of weight gain;
(c) body image disturbance
(d) absence of menstrual cycles or
amenorrhea in women (and loss of sexual interest
Criterion A focuses on behaviors, like restricting
But no longer includes the word ‘refusal’
in terms of weight maintenance since that implies
intention on the part of the patient
The DSM-IV Criterion requiring amenorrhea, is
This criterion cannot be applied to males, children,
OC, and post-menopausal females.
exhibit all other symptoms and signs of anorexia
nervosa but still report some menstrual activity
All 3 of the following:
Energy restriction leading to significantly low body
Fear of weight gain or behavior interfering with weight
Disturbance in self perceived weight or shape
Binge eating /purging type; recurrent episodes of
bingeing or purging in the last 3 months
Mild BMI>17 kg/m2
Few controlled trials to guide treatment
Weight restoration, family therapy and structured
Improve nutritional health – refeeding
Drugs can be used to treat co-morbid conditions
Limited role in weight restoration
Phosphate, K+, thiamine, Mg, Ca2+ supplementation in
results in a decrease in the serum levels of phosphate,
potassium, and magnesium, all of which are already
hormonal and metabolic changes are aimed at preventing
protein and muscle breakdown.
use fatty acids as the main energy source.
increase in blood levels of ketone bodies
brain to switch from glucose to ketone bodies as its main
The liver decreases its rate of gluconeogenesis, thus
preserving muscle protein.
several intracellular minerals become severely depleted
serum concentrations of these minerals (including
phosphate) may remain normal.
reduction in renal excretion.
During refeeding, glycaemia leads to increased insulin and
decreased secretion of glucagon.
Insulin stimulates glycogen, fat, and protein synthesis.
Insulin stimulates the absorption of potassium into the
cells through the sodium-potassium ATPase symporter,
which also transports glucose into the cells.
Magnesium and phosphate are also taken up into the cells.
Water follows by osmosis.
These processes result in a decrease in the serum levels of
phosphate, potassium, and magnesium
The clinical features of the refeeding syndrome occur as a
result of the functional deficits of these electrolytes and the
rapid change in basal metabolic rate.
rate of feeding should be slowed down and essential
electrolytes should be replenished.
Fluid repletion should be carefully controlled to avoid fluid
Bone loss complication serious consequences
Hormonal treatment with oestrogen or
dehydroepiandrosterone (DHEA) no positive effect on
Oestrogen not recommended in children and
adolescents – risk premature fusion of bones
2009 Cochrane review: no evidence from 4 placebo
On weight gain, eating disorder or associated
Suggested neurochemical abnormalities in starvation
may explain non-response
Co-prescribing supplementation incl. tryptophan with
fluoxetine does not increase efficacy
Olanzapine, benzodiazepines or promethazine to
reduce anxiety with refeeding
1 RCT showed 88% of patients given olanzapine
achieved weight restoration (55% placebo)
Quetiapine may improve psychological symptoms but
Small trial suggested that fluoxetine useful in
improving outcome and preventing relapse after
Other studies found no benefit
Antidepressants often used to treat co-morbid
depression and OCD
However these conditions may resolve with weight
Significant disturbance in eating manifested by
persistent failure to meet nutritional/energy
requirement associated with 1 of:
Significant weight loss
Significant nutritional deficiency
Dependence on enteral feeding or supplements
Interference with psychosocial functioning
NOT due to lack of food or body image disturbance
Avoidant/Restrictive Food Intake Disorder (ARFID) has
replaced Feeding Disorder of Infancy and Early Childhood
and EDNOS which was described in the DSM-IV.
While few data on ARFID have been published, it appears
that it usually presents in infancy or childhood, but it can
also present or persist into adulthood.
The course of illness for individuals relatively unknown.
Avoidance due to sensory characteristics of food, emotional
difficulties, food beliefs etc.
ARFID may be associated with impaired social functioning
and affect family functioning, especially if there is great
stress surrounding mealtimes.
The presence of other psychological disorders may be risk
factors for ARFID, such as anxiety disorders, obsessivecompulsive disorders, attention deficit disorders, and
autism spectrum disorders
If an individual presents with one of these illnesses and an
eating problem, a diagnosis of ARFID should be given only
when the feeding disturbance itself is causing significant
individuals with a history of gastrointestinal conditions
such as gastroesophageal reflux may develop feeding
disturbances, but a diagnosis of ARFID should be assigned
only when the feeding disturbances require significant
treatment beyond that needed for the gastrointestinal
Little is currently known about effective treatment
interventions for individuals presenting with ARFID
given the prominent avoidance behaviors, it seems
likely that behavioral interventions, such as forms of
depression or anxiety that affects feeding, cognitive
behavioral therapy and other treatments for the
Bulimia nervosa is characterized by recurrent and
frequent episodes of eating unusually large amounts of
feeling a lack of control over the eating.
purging (e.g., vomiting, excessive use of laxatives or
diuretics), fasting and/or excessive exercise
DSM-5 criteria reduce the frequency of binge eating
and compensatory behaviors to once a week from
twice weekly as specified in DSM-IV.
Psychological treatments first choice
Adults mat be offered antidepressants
SSRI’s esp fluoxetine
60mg effective dose
Can reduce frequency of binge eating and purging
Long term effects unknown
Early response at 3 weeks strong indicator of response
Used off licensed in adolescents
Some evidence for topiramate, duloxetine, lamotrigine and
sertraline reduce binges
Binge eating disorder will now have its own category as an
In the DSM-IV, under the category Eating Disorder Not
“recurring episodes of eating significantly more food in a
short period of time than most people would eat under
similar circumstances, with episodes accompanied by
feelings of lack of control.”
eat quickly and uncontrollably, despite hunger signals or
feelings of fullness.
feelings of guilt, shame, or disgust
behavior will have typically taken place at least once a week
over a period of three months.
Evidenced based self help programme of CBT as first
Trial of SSRI as an alternative or additional first step
Although AN is not a common condition
its morbidity and mortality are amongst the highest
due to malnutrition, purging
behavior and suicide.
18-fold increase in mortality in patients with AN
Over 7 years, the majority of women with anorexia
nervosa experienced diagnostic crossover: more than
half crossed between the restricting and binge
eating/purging anorexia nervosa subtypes over time;
one-third crossed over to bulimia nervosa but were
likely to relapse into anorexia nervosa. Women with
bulimia nervosa were unlikely to cross over to anorexia
Key is MDT
Dietician, psychology, medicine, psychiatry, OT and
Clearly defined case manager , roles of team members
in case defined