ASSESSMENT AND TREATMENT OF ANOREXIA AND BULIMIA NERVOSA by klutzfu43

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									ASSESSMENT AND TREATMENT OF
ANOREXIA AND BULIMIA NERVOSA

                Walter Kaye, MD
            Professor of Psychiatry
      Director, Eating Disorders Program
           Department of Psychiatry
      University of California San Diego
                wkaye@ucsd.edu
        http://eatingdisorders.ucsd.edu




            Classification


                EDNOS
             BN
              BN
     AN
               AN




                                           2




                                               1
DSM IV Anorexia Nervosa 307.1
• A. Refusal to maintain body weight at or above a
  minimally normal weight for age and height

• B. Intense fear of gaining weight or becoming fat,
  even though underweight.

• C. 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.

• D. In postmenarcheal females, amenorrhea, i.e., the
  absence of at least three consecutive menstrual
  cycles.
                                                          3




    Anorexia Nervosa Subtypes
• Restricting Type: during the current episode
  of AN, the person has not regularly engaged
  in binge-eating or purging behavior

• Binge-Eating/Purging Type: during the
  current episode of AN, the person has
  regularly engaged in binge-eating or purging
  behavior

                                                          4




                                                              2
   DSM IV Bulimia Nervosa 307.51
• A. Recurrent episodes of binge eating characterized by
   – (1) eating, in a discrete period of time (e.g., within any 2-hour period), an
     amount of food that is definitely larger than most people would eat during a
     similar period of time and under similar circumstances
   – (2) a sense of lack of control over eating during the episode (e.g., a feeling
     that one cannot stop eating or control what or how much one is eating)
• B. Recurrent inappropriate compensatory behaviors in
  order to prevent weight gain (self-induced vomiting; misuse
  of laxatives, etc)
• C. The binge eating and inappropriate compensatory
  behaviors at least twice a week for 3 months.
• D. Self-evaluation unduly influenced by body shape and
  weight.
• E. The disturbance does not occur during episodes of AN.

                                                                              5




                                                                              6




                                                                                      3
7




8




    4
    Nervous Consumption”
       (Morton, 1689)
 Mrs. Duke’s daughter, in the eighteenth year of
 her age, fell into a total suppression of her
 monthly courses from a multitude of cares and
 passions of her mind...from which time her
 appetite began to abate. She thus neglected
 herself for two full years. Never did I see one
 conversant with the living, so much wasted, yet
 there was no fever, no distemper of the lungs, or
 signs of preternatural expence of the nutritious
 juices. Only her appetite was diminished.       9




           Anorexia Nervosa
• Many women diet in our culture
• Relatively few develop anorexia nervosa
• Are there susceptibility factors that make some
  women vulnerable to dieting, weight loss?




                                               10




                                                     5
        New Biology of AN and BN
• Family studies
      • Increased rate of AN, BN, ED NOS in first degree relatives
      • AN, BN cross transmitted in families, share etiologic features
      • AN, BN not related to BED
• High Heritability in Twin Studies (50 to 80%)
• Genes code for susceptibility factors (pre-morbid, persist after
  recovery) in AN, BN; NOT THE DIAGNOSTIC ENTITY
      • Obsessed with body image, weight, food
      • Obsessions - perfectionism, symmetry, exactness
      • Negative affect, harm avoidance, anxiety, depression
• Evidence that neurobiology contributes to causing ED
• Behavioral traits exaggerated by malnutrition, but persists after
  recovery
                                                                     11




                     Symptoms and
                     Clinical Course




                                                                          6
           Subtypes of Eating Disorders
    DSM-IV                           AN                  AN-BN          BN

    % prevalence                    0.25                   0.25         1-3

    % women                          95                    95           90

    Weight                          Low                    Low        Normal

    Eating                       Restrict                Restrict,    Restrict,
                                                          binge        binge
    Mood/                          Over                 Over/under   Over/under
    impulse control               control                control      control
AN-BN=anorexia nervosa, binge-eating/purging subtype.                          13
APA. DSM-IV-TR; 2000.




                              Clinical Course
     •    Onset adolescents/puberty
     •    Mainly female
     •    Body image distortions, fear of being fat
     •    Dieting but preoccupation with food
     •    Profound weight loss < 75% avg body weight
     •    Denial, resistance to treatment
     •    Course
           – 50+% recover
           – 30% chronically ill
           – 10%+ die
                                                                               14




                                                                                    7
    Symptoms in Eating Disorders
                                       AN       AN-BN      BN

Body image distortion                   +          +        +

Neg affect, perfect, obsessive          +          +        +

Exercise                                +          +

Anhedonic                               +

Denial, resistance, ego syntonic        +          +
Drugs, alcohol, poor impulse                       +        +
control                                                      15




   Why Pathologic Feeding Behavior?

 • AN: Anxiety reducing character to dietary
   restraint (Kaye, 2003; Strober, 1995; Vitousek, 1994)

 • BN: overeating is thought to relieve dysphoria
   and/or anxiety (Abraham, 1982; Kaye, 1986; Johnson 1982; Strober
    1994)




                                                             16




                                                                      8
                                                         Cumulative Probabilities
                                                   of Recovery From Anorexia Nervosa
                                                                         Strober et al, IJED, 1997


     P r o b a b ility o f R e c o v e r y    1

                                             0.8

                                             0.6

                                             0.4

                                             0.2

                                              0
                                                   0      12 24 36 48 60 72 84 96 108 120 132 144 156 168 180
                                                                                     Months
                                                                                                                              17
                                                                       Partial Recovery         Full Recovery




                Symptoms in Ill AN Patients Compared
                  to Healthy Control Women (CW)
                                                  Speilberger Trait Anxiety                         Obsessions
                                                                                                 Compulsions (Y-BOCS)
                                             60
                                             50
                                             40                                           15
                                             30                                           10
                                             20
                                             10                                            5
                                              0                                            0
                                                        Control   Ill AN Women                    Control      Ill AN Women
                                                        Women                                     Women



                                                   Perfectionism (MPS)                          Drive for Thinness (EDI)
                                   150                                                     20
                                   100                                                     15
                                                                                           10
                                             50
                                                                                            5
                                              0
                                                       Control    Ill AN Women              0
                                                       Women                                         Control   Ill AN Women
                                                                                                     Women

Y-BOCS = Yale-Brown Obsessive Compulsive Scale; MPS = Multidimensional Perfectionism Index;
EDI = Eating Disorder Index                                                                                                   18




                                                                                                                                   9
                    Rates of
            Major Depressive Disorder
                             Probands                                                        Relatives
        AN                   43%-86%                                                         6%-25%
        BN                   30%-98%                                                         11%-50%
        Winokur 1980, Gershon 1983; Hudson 1983, 1987; Rivinus 1984;
        Piran1985; Bulik, 1987; Logue 1989; Kassett 1989; Strober 1990;
        Fornari 1992; Herzog 1992; Kennedy 1994; Bushnell 1994;
        Boumann & Yates, 1994; Deep 1995; Brewerton1995;
        Garfinkel1995; Lilenfeld 1998, Kaye submitted

        30% have onset of MDD in childhood, before AN or BN




                                                                                                                          19




 Lifetime OCD Diagnosis in AN, BN
                                       Price Foundation Genetic Collaborative Study
      Review of Literature                         Total 1416 subjects
         Godart 2002                 DSM IV, SCID I, Y-BOCS MS/PhD Clinical Interview
                                               N. America, England, Germany


 Diagnosis             Range                                                     60
                                          P e r c e n t w it h D ia g n o s is




                                                                                 50
 AN                  10 – 62%
                                                                                 40

 AN BN               10 – 66%                                                    30

                                                                                 20

 BN                   0 – 43 %                                                   10

                                                                                  0
                                                                                      AN (n 619)   AN BN (n 515)   BN (n 282)



                              1-             2-
General population rate OCD: 1-3% of adults; 2-4% of children
                                                        20
(Grados 97, Riddle 98; Serpell 02)




                                                                                                                                10
             Childhood Symptoms of Obsessive-Compulsive
              Personality Traits: Percentage of Individuals
                               With Traits
                   100
                                        AN (n=26)        AN-BN (n=18)      BN (n=28)
                    80
   % of Patients




                    60

                    40

                    20

                      0
                               Perfectionistic             Inflexible            Rule Bound

                                                                                              21
Anderluh MB, et al. Am J Psychiatry. 2003;160(2):242-247.




                               Anxiety Disorders (AD)
                           Lifetime and Premorbid Rates
                   Study                ED          n        Lifetime AD           AD before ED

                   Deep 95              AN          24           68%                   58%

                   Bulik 97             AN          68           60%                   54%

                   Bulik 97             BN       116             57%                   54%

                   Godart 00            AN          29           83%                   62%

                   Godart 00            BN          34           71%                   62%

                   Kaye 04            AN,BN      672             64%                   61%
                                                                                    23% OCD
                                                                                 13% social phobia

                                                                                              22




                                                                                                     11
         Course and Symptoms in AN




                                                                         23




                Impulse Control
            Alcohol/Substance Abuse
• Higher prevalence in BN subjects and families compared
  with general population
   – Low in restrictor-type AN
• BN and SB – Alcohol and food can become strategies to
  relieve intense affects in people with difficulties in self-
  soothing.
• BUT
   – INDEPENDENTLY transmitted
   – Perhaps ED lowers threshold for expression of SA (if risk exists)
   – ED NOT form of addiction
• Cluster B/multi-impulsive disorder
   – Perhaps 25% of BN
   – Associated with poor outcome                                        24




                                                                              12
              Why Female Adolescents?
                            Connan, Treasure 2003

• Psychological: Change, independence, stress, social
  expectations may challenge the rigidity of those at risk for AN,
  or emotional vulnerability of AN and BN, and thus fuel an
  underlying vulnerability
• Puberty: Twin studies (Klump 2000) show no genetic influence
  on ED symptoms in 11 year-old twins, but significant genetic
  effects in 17 year old twins
• Menarche/gender: Female gonadal steroids alter serotonin,
  other brain systems that affect feeding, emotionality, etc
• Brain Development: Synaptogenesis, pruning and myelination
  of frontal and limbic areas occurs around the time of puberty
  and adolescence, and may effect the integration of emotional
  processing with cognition {Benes, 1998}.
• Body Development: Rapid (fat) weight gain
                                                                           25




            Relevant AN Clinical Issues
     • Highest use of inpatient beds after schizophrenia, MR
     • Common to shift between subtypes over time
     • Substantial medical complications
        – Consequence weight loss, malnutrition, duration, substance use
     • Cognitive and behavioral impairments (exaggerated by
       weight loss)
        –   Ego-syntonic, denial, resistance
        –   Body image distortions, pursuit of thinness
        –   Anhedonia
        –   Cognitive distortions
        –   Set shifting
        –   Details > Central coherence
        –   Difficulty learning from experience
                                                                           26




                                                                                13
         Treatment of AN
    Management and Weight Gain




     Treatment of Anorexia Nervosa
• First Generation
      •   Weight Restoration
      •   Behavior Modification
      •   Antidepressants, neuroleptics unsuccessful/unproven
      •   Successful inpatient weight gain, but high relapse
• Second Generation
      •   Relapse Prevention
      •   Specialized Psychotherapies (Family, CBT, DBT, etc)
      •   Control trials - SSRI’s, etc
      •   Goal: Response without hospitalization, reduced relapse




                                                                    28




                                                                         14
                              Why is it difficult to gain weight?
                              • The numbers (50 kg/110 lb women)
                                   – Normal 30 cal/kg/d maintain (1500 cal/d)
                                   – AN weight gain > 70 cal/kg/d (3500+ cal/d)
                                      • For weight gain of 2 to 3 lb/wk
                                   – AN weight maintenance 50 cal/kg/d (2500 cal/d)
                              •   AN want to eat <1000 cal/d
                              •   Starvation and weight loss – ego syntonic
                              •   Increased dysphoria before and during meals
                              •   Food and weight obsessions and rituals
                                   – Stereotypic food choices, ritualized eating, calorie counting
                                   – Delusionary quality
                                   – Nothing else is more important
                              • Food “blindness”
                                   – Lack of homeostatic mechanism that drives hunger when starved


                                                                                                         29




                                        % Average Body Weight and Calories/kg per Day

                        100                                                                                   90


                        95                                                                                    80


                        90                                                                                    70
% Average Body Weight




                                                                                                                   Calories/kg per day




                        85                                                                                    60


                        80                                                                                    50


                        75                                                                                    40


                        70                                                          Cal/kg/day                30


                        65                                                                                    20
                         January      February    March       April          May   June          July   August
                                                                      DATE                               30




                                                                                                                                         15
  Eating behavior in AN – Weight
               loss
• Healthy women need 20 – 40 kcal/kg/day to
  maintain weight
• Weight loss in AN
  – Rarely stop eating
  – 200 – 500 kcal/day (< 20 kcal/kg)
  – Relatively low fat, high carbohydrate, normal protein as % of daily
    caloric intake
  – Vegetarian, red meat avoiding
  – Similar food choices every day
  – Ritualistic, often odd combinations


                                                                  31




 Eating behavior AN – Weight gain
 • Need >40 to 50 kcal/kg to gain weight
 • Often need to increase to maintain gain of 1 kg/week
 • Can get to 80 to 100 kcal/kg/day
        • 40 kg women = 4000 kcal/day
        • Order magnitude more than eating at home
 • Accompanied by high temperature, sweating especially
   at night
 • Caloric needs related to exercise




                                                                  32




                                                                          16
  Eating behavior in AN – After weight
              restoration

• Hypermetabolic after weight restoration
   – RAN need 50 to 60 kcal/kg/day
   – BAN need 40 to 50 kcal/kg/day
   – 50 kg women = 2000 to 3000 kcal/day
• Probably normalizes in long term
• Probable contribution to high rate of relapse




                                                  33




Influence of malnutrition on therapy
• Starvation produces substantial changes in
  brain neurotransmitters
• Contributes to
   – Endocrine, autonomic, etc disturbances
   – Mood and cognitive alterations
   – May confound drug response
• Nutritional restoration KEY component of
  treatment


                                                  34




                                                       17
           Weight maintenance
• Key to success in treatment program
  – Low stress and conflict, high structure, nurture
  – Alliance with family
  – Learn from failure
• Long-term more difficult
  – High rate of relapse
  – Difficult to keep up with metabolic needs
  – Self-soothing benefits of dietary extremes




                                                       35




                    AN
              TALK THERAPIES




                                                            18
             AN Prospective
       Controlled Treatment Studies
• Few studies, small n’s, short-term follow-up
• Psychotherapy: few controlled studies
     • compare different interventions
     • Aid nutritional recovery (family based, CBT, DBT) or prevent
       relapse
• Pharmacotherapy (double blind placebo control)
     • Drugs don’t improve weight restoration
     • Prozac relapse prevention after weight gain




                                                                     37




  Recent Psychotherapy Advances
  • Adolescent AN
     – Family-based therapies (Lock, LeGrange) are promising
        • Outpatient studies on less severely ill AN
  • Adult AN
     – Cognitive-behavioral therapy (Pike 2003)
        • Promising, but few had full recovery and relatively high
          drop out rates




                                                                     38




                                                                          19
Family Based (Maudsley) Treatment
 for Adolescent Anorexia Nervosa
• Five studies suggest that family-based treatment
  based on parental re-feeding is effective for
  adolescents
   – Russell et al (1987)—90% improvement in subgroup of with short-
     duration AN
   – Le Grange et al (1992)—70% improvement
   – Robin et al (1999)—90% improvement with family treatment
     compared to 65% with individual therapy
   – Eisler et al (2000)—65% improvement in cohort
   – Eisler et al (1997)—five year follow-up on Russel et al (1987) found
     improvements were maintained.




                                                                       39




             Treatment Approach
– Agnostic view of cause of illness (No blame)
– Initial symptom focus
– Family made responsible to re-feed child
  (Empowerment)
– Non authoritarian therapeutic stance (Joining)
– Separation of child and illness (Respect for adolescent)




                                                                       40




                                                                            20
              Treatment Aims
• Highly focused, staged treatment
• Emphasis on behavioral recovery rather than
  insight and understanding
• Indirect approach to improving family
  functioning
• Supports gradually increased independence
  from therapy


                                                            41




           Treatment Structure
• Three Phases
  – Phase 1--Re-feeding--parents encouraged to take charge of
    helping their child eat.
  – Phase 2--Assisting parents in helping adolescent take
    charge of eating on her own
  – Phase 3--Address general adolescent concerns as effected
    by AN




                                                            42




                                                                 21
                       AN
                   MEDICATION




SSRI’S HAVE NO EFFECT ON SYMPTOMS
  OR PREVENTING HOSPITALIZATION
   IN UNDERWEIGHT AN SUBJECTS
• Prospective controlled SSRI inpatient trial (Attia
  1998)
• Presence/absents SSRI – no effect on symptoms
  on admission (Ferguson 1999)
• BUT
  – Total n < 50
  – Need for rigorous controlled large-scale trial




                                                     44




                                                          22
Proportion of Weight Recovered AN Remaining Well
                   as Outpatients
               Fluoxetine vs Placebo

                                             1.0
                                                                                        Placebo (N=19)
                                             0.9
                                                                                        Fluoxetine (N=16)
     Proportion of Subjects Remaining Well




                                             0.8
                                             0.7
                                             0.6
                                             0.5
                                             0.4
                                             0.3
                                             0.2
                                             0.1
                                             0.0
                                                   0   40   80   120   160 200 240      280    320    360   400
                                                                        Days in Study
                                                                                                                  45




                                                   Relapse prevention in AN
    Fluoxetine vs placebo in subjects getting CBT
AN patients remaining in treatment vs number of weeks after treatment inception
                               Walsh et al 2006




                                                                                                                  46




                                                                                                                       23
   Atypicals – Case reports and open trials
       Severe, chronic, ill AN patients
• Olanzapine
   –   Hansen 1999; La Via 2000; Jensen 2000; Powers 2002; Malina 2003; Barbarich 2004

• Risperidone
   –   Fisman 1996; Newman-Toker 2000

• Quetiapine
   –   Powers, APA new research poster 2004

• AN subjects
   – Gained weight
   – Reduced agitation and less resistance to treatment
   – None had co-morbid schizophrenia
• “Atypical antipsychotic”
   – Dopamine, serotonin, other actions
• Need for controlled trials


                                                                                         47




                   Medications - summary
  • SSRI’s, other antidepressants
       – Few controlled trials
       – Not effective in ill AN (but no large scale trials)
       – Possibility SSRI reduce relapse after weight restoration
  • Atypical “antipsychotics”
       – May reduce dysphoria, increase weight in ill AN
       – Requires controlled trial to prove this




                                                                                         48




                                                                                              24
        AN Treatment Guidelines




                    Summary
                 Treatment for AN
• Few “controlled” trials of treatment
• We know little about how treatments compare to each
  other, or what is best over the long-term
• Important benefit to reversal of malnutrition, weight loss
   – Minimizes medical consequences
   – Stops downward spiral
   – Prevents dying of malnutrition




                                                          50




                                                               25
         AN: Hospital vs Outpatient Treatment

                                             Outpatient              Inpatient

Weight                                         >85%                   < 75%

Medical complications                           none             ↓ HR, BP, K etc

Suicidal, comorbid psych disorders          Not present               severe

Motivation, insight, cooperation                 yes                    no

Exercise, purge, etc                          minimal                 severe

Stress, family dynamics                       minimal                 severe

Local ED treatment resources                  available                none
                                                                              51




                  Treatment Guidelines
     • AN, AN-BN
         –   Denial, resistance, perceptual distortions
         –   Not respond to medication if malnourished
         –   If gentle limit setting not successful, refer to an ED specialist
         –   Many have prolonged, chronic course with multiple relapses
         –   Minimize medical problems – refeed, weight restoration
     • Weight restoration “guidelines”
         •   2 to 3 lbs/wk inpatient
         •   1 to 2 lbs/wk day-hospital
         •   1 lb/wk outpatient
         •   Fluid balance, laxatives, purge behavior may affect rate

                                                                              52




                                                                                   26
        NEED FOR
 IMPLEMENTATION OF NEW AN
       TREATMENTS

                      EXAMPLES




NIMH Supported Multi-site Study
      of Adolescent AN
_______________________________________________________________________


 4 cell design
    “Maudsley” vs psychodynamic Family Therapy
    Fluoxetine vs placebo
 7 sites: UCSD, Wash U, Laureate, Sheppard-
 Pratt, Cornell, Toronto with core at Stanford
 Total 240 adolescents with AN
 48 week therapy with additional 6 month med
 continuation
 No cost to participants

                                                                          54




                                                                               27
      University of California San Diego
AN Comprehensive Evaluation and Intensive
          Family-based Treatment
• Issues:
  – Expert advice, intervention for AN difficult to find
  – Goal: Family understanding and management of AN
  –       Reduce relapse
• AN, parents, sibs stay at local SD Hotel
• One week (Mon-Fri) La Jolla ED offices
  –   Comprehensive medical, psychological evaluation
  –   Psychoeducation “facts” about Anorexia Nervosa
  –   Medication evaluation
  –   Maudsley Family therapy introduction
  –   Consultation with home therapist/physician
  –   Follow up therapy after discharge
                                                           55




  Treatment of Bulimia Nervosa




                                                                28
     Treatment of Bulimia Nervosa
• Outpatient, partial programs often successful
• Proven treatments (in controlled trials)
   – Medication “Antidepressants”
   – Psychotherapy
      • CBT - “gold” standard
      • Interpersonal, dialect therapies
   – Reduce binge/purge, improve function and mood
• CBT + Medication – interactions not clear
• Cluster “B” PD respond poorly

                                                      57




            Pharmacotherapy of BN
• 20+ double blind, placebo controlled studies
      • most parallel, short term
      • few cross-over
• Most show active >> placebo reductions of Binge, Purge
      • Minority abstinent
• Trials short term, small number subjects
• Less focus on response of
      •   OCD
      •   Impulse control
      •   Anxiety, depression
      •   Core ED symptoms
      •   Cluster B

                                                      58




                                                           29
                     Double-Blind, Placebo-Controlled Trials
                               of Antidepressants
                        % Reduction of Binges, Purges
                                           22 reports, 1562 subjects
                            70
% Reduction from Baseline



                            60
                            50
                            40                                                          Drug
                            30                                                          Placebo

                            20
                            10
                            0
                                         Binge                    Purge

                                                                                              59




                                     % OF BN SUBJECTS THAT
                                 RESPONDED (>50% IMPROVEMENT)
                                  AFTER PLACEBO OR FLUOXETINE
                                                 Arch Gen Psych 1992

                            70                       a                             a
                            60
   % of "responders"




                            50                                                 b
                            40
                            30
                            20
                            10
                             0
                                            Binge                          Vomit

                                       Placebo       Fluox 20mg           Fluox 60 mg

                                 Fluoxetine vs placebo, a (p<.01), b (p<.05)                  60




                                                                                                   30
                      Fluvoxamine
• Two small controlled trials showed efficacy
  {Milano, 2005 ;Fichter, 1996}
• Trial of 267 BN in United Kingdom {Schmidt,
  2004}
  – fluvoxamine performed no better than placebo for short- or long-
    term (1 year) treatment of BN outpatients
  – Dose range of 50mg-300mg may have been too low
  – Adverse events were a problem for many patients, and titration to
    higher doses may not have been tolerated
• Little evidence exists for use of fluvoxamine as an
  SSRI of choice in BN

                                                                 61




                        Other Drugs
 • Sertraline (Milano 2004)
    – 20 BN, randomized trial
    – Drug better than placebo in reducing BP
    – Dose 100mg/day
 • Bupropion (Horne 1988)
    –   69 BN, controlled trial
    –   Drug better than placebo in reducing BP
    –   4 of 69 patients had seizures (never replicated)
    –   Contraindicated in BN
 • Ondansetron (anti-emetic, 5HT3 receptor effects)
   (Farris 2000)
    – 4 week controlled trial 25 BN
    – Ondansetron better than placebo in reducing BP
    – Questions regarding
        • Potential side effects
        • Likelihood of compliance with multiple daily dosing
        • Cost
        • Impact on psychological features
                                                                 62




                                                                        31
                     Topiramate
• Anticonvulsant topiramate has been linked to appetite
  suppression and weight loss. {Appolinario, 2004}
• 10 week, DBPC study {Hoopes, 2003; Hedges, 2003}
   – Maximum dose of 400 mg/day (median 100 mg/day)
   – Topiramate better than placebo in reducing BP
• 10 week DBPC study (Nickel 2005)
   – Maximum 250 mg/day
   – Topiramate better than placebo in reducing BP
   – Topiramate group had a decrease in weight
• Both studies reported few adverse side effects
• Not know if has long-term efficacy
• Weight loss a concern in this population

                                                      63




               Medication Issues
              in Treatment of BN
           • Tricyclics
                    • Autonomic side effects
           • MAOI’s
                    • Indiscriminate binge eating
                    • Drug abuse, diet pills, etc.
           • Bupropion
                    • seizures
           • Lithium
                    • fluid balance


                                                      64




                                                           32
    Is BN a depressive variant?
• FOR
     • response to antidepressants
     • high rate of depression in BN, relatives
• AGAINST
     • Depression exaggerated by pathologic eating
     • Separate transmission of depression in families
     • Non-depressed BN respond to antidepressants


• Unlikely depressive variant accounts for
  response to treatment

                                                         65




 How do “Antidepressants” work
     in Eating Disorders?
     •   Increase satiety
     •   Reduce obsessions
     •   Reduce sensitivity to stress
     •   Normalize impulse control
     •   Decrease negative affect




                                                         66




                                                              33
                                            Summary
                                          Medication in BN
•                    Main effect: reduced binge, purge
•                    ?Reduction negative affect, obsessions
•                    Response similar all antidepressant classes
•                    No studies comparing efficacy of 2 or more different
                     drugs
•                    Choice related to side effects
•                    Dose similar (or greater) major depression
•                    Cluster B personality disorder - ?worse outcome
•                    Long term maintenance not well studied
                                 • antibinge attenuation over time in some


                                                                                                  67




                                Psychotherapy in Bulimia Nervosa
                                      Fairburn et al, Arch Gen Psych 1993


                                 60
    % Abstient - binge, purge




                                 50

                                 40                                                     IPT
                                                                                        CBT
                                 30
                                                                                        BT (dietary)
                                 20
                                                                                      p < .05
                                 10
                                                                                      IPT vs BT
                                  0
                                 BEGIN      END         4 mo           8 mo   12 mo
                                                  Stage of treatment

                                                                                                  68




                                                                                                       34
            Summary - Drug and/or
             Psychotherapy in BN
• Benefit of adding drug to structured psychological
  treatment, but of small magnitude
• No clinical guidelines identify which patient responds to
  which treatment
• BN who get greatest benefit from treatment typically
  exhibit an early response
• Recommendations
      • May be useful to initiate treatment with CBT
      • If not successful, add another intervention, such as medication
      • Medication may be useful for those not responding adequately to or
        relapsing after psychological treatment




                                                                      69




                       SUMMARY
 • Progress made over last 20 years
 • Efficacy mainly shown for CBT and
   antidepressant medication
 • At best, about 50+% of patients achieve
   remission with CBT or antidepressants
 • Significant number of relapses with both
   types of treatment


                                                                      70




                                                                             35
     ED Treatment References
• NICE National Institute for Clinical Excellence
  guidelines for AN and BN (Jan 2004)
  – www.nice.org.uk


• American Psychiatric Association. (2006)
  Practice guideline for the treatment of
  patients with eating disorders, 3rd ed.
  American Psychiatric Association.

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