Medication management of pediatric eating disorders

This article provides an overview of psychopharmacological treatments for pediatric eating disorders (EDs). Although EDs usually begin in adolescence, there are few pharmacological treatment trials specific to this age group and a paucity of controlled data. Empirical evidence suggests that psychological, behavioural and family interventions should be the primary modalities of treatment for these conditions. In severely underweight patients behavioural weight restoration should be attempted before pharmacological intervention, especially since starvation is known to aggravate obsessional and depressive symptomatology. Evidence from controlled trials supports the use of antidepressants for the treatment of bulimia nervosa (BN) in adults; however, similar studies have not yet been performed in youths. For anorexia nervosa (AN), there are no pharmacotherapies of proven efficacy in either adults or youths. Nonetheless, clinical experience and uncontrolled evidence suggests that some children and adolescents may benefit from thoughtful use of psychotropic medications on an individual basis in the context of a multimodal treatment plan. Regarding binge eating disorder (BED), adult literature shows positive short-term effects on binge eating for both pharmacological (especially selective serotonin reuptake inhibitors) and behavioural interventions, but unclear effects on weight. Clearly, psychopharmacological interventions for pediatric EDs would benefit from more research.     

Current drug treatment of patients with bulimia nervosa and binge-eating disorder: selective serotonin reuptake inhibitors versus mood stabilizers

Our aim was to review and compare findings from controlled trials and previous reviews concerning current drug treatment of patients suffering from bulimia nervosa (BN) and binge eating disorder (BED). Thus we selected published articles quoted over the last 10 years in the databases of Medline and Cochrane Library. The combination of pharmacological and psychological treatments is superior to the single psychotherapeutic approach, which in turn is superior to single drug treatment (just superior to placebo). Among drug treatments, SSRIs are the first line choice treatments, especially in primary care. They are more acceptable and tolerated by patients, moreover effective even if investigations on long-term outcomes are lacking. A number of patients, however, do not respond to these drugs. For them it is necessary to find new therapeutic strategies. Mood stabilizers are promising in this regard. In particular, topiramate seems to allow reduction of binge eating and weight in SSRI non-responder patients.     

Self-help treatments for disorders of recurrent binge eating: a systematic review

OBJECTIVE: To evaluate self-help interventions for patients with binge eating disorder (BED) and bulimia nervosa (BN), tested in randomized controlled trials, and compared with waiting list or any other type of control group. METHODS: A systematic review including quality appraisal was conducted of randomized controlled trials, using self-help techniques in patients with BED and/or BN. Six databases were searched during the period between January 1994 and June 2004. RESULTS: A total of 2686 articles were identified, 1701 abstracts were evaluated in detail and, nine studies fulfilled the inclusion criteria for this review. All studies indicated that patients treated with active interventions had a reduced number of binge eating episodes at end of treatment. CONCLUSION: The results support self-help interventions but shall be interpreted with caution. Because of the small number of studies using self-help techniques for BED and BN, further larger randomized, multi-center controlled studies that apply standardized inclusion criteria, evaluation instruments and self-help materials, are needed.     

Treatment implications of Axis-II comorbidity in eating disorders

In this article, we review the clinical research on the implications of comorbid personality disorders (PDs), pathological personality traits, and the expression and response to treatment of those with eating disorders (EDs) (i.e., anorexia and bulimia nervosa, and binge eating disorder). Obsessive-compulsive PDs and related traits, such as perfectionism and rigidity, appear to be clear-cut risk and maintenance factors for anorexia nervosa. In bulimia nervosa, trait impulsivity seems to be related to early termination from therapy and, according to at least some indices, poorer responses to treatment. Dramatic-Erratic PD features, generally more characteristic of binge-purge ED variants, clearly predict a protracted course for general psychiatric symptoms, but may have less prognostic value for eating symptoms. Recent guidelines from two influential bodies--the American Psychiatric Association (APA, 2000) and the United Kingdom's National Institute for Clinical Excellence (NICE, 2004)--both include the concept that "trait-oriented" interventions, targeting personality-linked components like perfectionism, affective instability, impulsivity, and interpersonal disturbances, may optimize treatment effects. In general, the literature supports the recommendation that clinicians should apply well-validated, symptom-focused therapies for the EDs; in addition, clinicians may wish to incorporate trait-focused interventions in patients in whom personality pathology contributes to suboptimal response.     

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Pharmacological Treatment of Eating Disorders

Abstract

Objectives. The treatment of eating disorders is a complex process that relies not only on the use of psychotropic drugs but should include also nutritional counselling, psychotherapy and the treatment of the medical complications, where they are present. In this review recommendations for the pharmacological treatment of eating disorders (anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED)) are presented, based on the available literature. Methods. The guidelines for the pharmacological treatment of eating disorders are based on studies published between 1977 and 2010. A search of the literature included: anorexia nervosa bulimia nervosa, eating disorder and binge eating disorder. Many compounds have been studied in the therapy of eating disorders (AN: antidepressants (TCA, SSRIs), antipsychotics, antihistaminics, prokinetic agents, zinc, Lithium, naltrexone, human growth hormone, cannabis, clonidine and tube feeding; BN: antidepressants (TCA, SSRIs, RIMA, NRI, other AD), antiepileptics, odansetron, d-fenfluramine Lithium, naltrexone, methylphenidate and light therapy; BED: antidepressants (TCA, SSRIs, SNRIs, NRI), antiepileptics, baclofen, orlistat, d-fenfluramine, naltrexone). Results. In AN 20 randomized controlled trials (RCT) could be identified. For zinc supplementation there is a grade B evidence for AN. For olanzapine there is a category grade B evidence for weight gain. For the other atypical antipsychotics there is grade C evidence. In BN 36 RCT could be identified. For tricyclic antidepressants a grade A evidence exists with a moderate-risk-benefit ratio. For fluoxetine a category grade A evidence exists with a good risk-benefit ratio. For topiramate a grade 2 recommendation can be made. In BED 26 RCT could be identified. For the SSRI sertraline and the antiepileptic topiramate a grade A evidence exists, with different recommendation grades. Conclusions. Additional research is needed for the improvement of the treatment of eating disorders. Especially for anorexia nervosa there is a need for further pharmacological treatment strategies.     

Treatment Implications of Axis-II Comorbidity in Eating Disorders

In this article, we review the clinical research on the implications of comorbid personality disorders (PDs), pathological personality traits, and the expression and response to treatment of those with eating disorders (EDs) (i.e., anorexia and bulimia nervosa, and binge eating disorder). Obsessive-compulsive PDs and related traits, such as perfectionism and rigidity, appear to be clear-cut risk and maintenance factors for anorexia nervosa. In bulimia nervosa, trait impulsivity seems to be related to early termination from therapy and, according to at least some indices, poorer responses to treatment. Dramatic-Erratic PD features, generally more characteristic of binge-purge ED variants, clearly predict a protracted course for general psychiatric symptoms, but may have less prognostic value for eating symptoms. Recent guidelines from two influential bodies—the American Psychiatric Association (APA, 2000) and the United Kingdom's National Institute for Clinical Excellence (NICE, 2004)—both include the concept that “trait-oriented” interventions, targeting personality-linked components like perfectionism, affective instability, impulsivity, and interpersonal disturbances, may optimize treatment effects. In general, the literature supports the recommendation that clinicians should apply well-validated, symptom-focused therapies for the EDs; in addition, clinicians may wish to incorporate trait-focused interventions in patients in whom personality pathology contributes to suboptimal response.     

Family-based therapy for adolescents with bulimia nervosa

Bulimia nervosa is occurring with increasing frequency among adolescents. Yet, no studies have examined effective treatments for this patient population. Involving the family in the treatment of adolescents with anorexia nervosa has proven to be helpful. A small series of cases has demonstrated that family-based treatment might also be beneficial for adolescents with bulimia nervosa. Moreover, treatment studies for adolescents with anorexia nervosa have demonstrated that family-based treatment does benefit binge eating/purging anorexics. Therefore, preliminary evidence seems to support the use of family-based treatment for adolescent bulimia nervosa. In this article, we review our current knowledge of family-based treatment for adolescents with an eating disorder, and present a case that has completed treatment in order to demonstrate the outline and main interventions of this manualized treatment. While this case demonstrates the successful resolution of bulimia in an adolescent female, at least in the short term, the efficacy of family-based treatment for this patient population is yet to be determined, and is currently being examined in a randomized controlled study at The University of Chicago.     

The epidemiology of eating disorders in six European countries: Results of the ESEMeD-WMH project

Few data are available to estimate the prevalence of eating disorders (EDs) and their correlates in the community. This paper reports data on EDs obtained in the framework of the ESEMeD project, aimed at investigating the prevalence of non-psychotic mental disorders in six European countries (Belgium, France, Germany, Italy, the Netherlands and Spain), using a new version of the Composite International Diagnostic Interview. The ESEMeD study was a general population cross-sectional household survey. In total, 21,425 respondents aged 18 or older provided data for the project between January 2001 and August 2003. A subsample (N = 4139) underwent a detailed investigation on EDs. Lifetime estimated prevalence of anorexia nervosa, bulimia nervosa, binge eating disorder, sub-threshold binge eating disorder, and any binge eating were 0.48%, 0.51%, 1.12%, 0.72%, and 2.15%, respectively, and they were 3-8 times higher among women for all EDs. However, since people under 18 were excluded from this study, our prevalence should be taken as lower-bound estimate of real frequencies. Indeed, cumulative lifetime prevalence analysis showed that the majority of eating disorders had their initial onset between 10 and 20 years of age. Role impairment and comorbidity with other mental disorders were highly common, yet only small proportions of patients with a lifetime diagnosis of EDs requested medical treatment. It still has to be proven whether early diagnostic identification and access to specialized care can reduce the burden caused by these disorders.     

Combining Pharmacological and Psychological Treatments for Binge Eating Disorder: Current Status,Limitations, and Future Directions

Binge eating disorder (BED) is characterized by recurrent binge eating and marked distress about binge eating without the extreme compensatory behaviors for weight control that characterize other eating disorders. BED is prevalent, associated strongly with obesity, and is associated with heightened levels of psychological, psychiatric, and medical concerns. This article provides an overview of randomized controlled treatments for combined psychological and pharmacological treatment of BED to inform current clinical practice and future treatment research. In contrast to the prevalence and significance of BED, to date, limited research has been performed on combining psychological and pharmacological treatments for BED to enhance outcomes. Our review here found that combining certain medications with cognitive behavioral therapy (CBT) or behavioral weight loss (BWL) interventions produces superior outcomes to pharmacotherapy only but does not substantially improve outcomes achieved with CBT/BWL only. One medication (orlistat) has improved weight losses with CBT/BWL albeit minimally, and only one medication (topiramate) has enhanced reductions achieved with CBT in both binge eating and weight. Implications for future research are discussed.     

The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication.

BACKGROUND: Little population-based data exist on the prevalence or correlates of eating disorders. METHODS: Prevalence and correlates of eating disorders from the National Comorbidity Replication, a nationally representative face-to-face household survey (n = 9282), conducted in 2001-2003, were assessed using the WHO Composite International Diagnostic Interview. RESULTS: Lifetime prevalence estimates of DSM-IV anorexia nervosa, bulimia nervosa, and binge eating disorder are .9%, 1.5%, and 3.5% among women, and .3% .5%, and 2.0% among men. Survival analysis based on retrospective age-of-onset reports suggests that risk of bulimia nervosa and binge eating disorder increased with successive birth cohorts. All 3 disorders are significantly comorbid with many other DSM-IV disorders. Lifetime anorexia nervosa is significantly associated with low current weight (body-mass index <18.5), whereas lifetime binge eating disorder is associated with current severe obesity (body-mass index > or =40). Although most respondents with 12-month bulimia nervosa and binge eating disorder report some role impairment (data unavailable for anorexia nervosa since no respondents met criteria for 12-month prevalence), only a minority of cases ever sought treatment. CONCLUSIONS: Eating disorders, although relatively uncommon, represent a public health concern because they are frequently associated with other psychopathology and role impairment, and are frequently under-treated.     

Emotional eating in anorexia nervosa and bulimia nervosa

ObjectivesThe relationship between emotional states and eating behaviors is complex, and emotional eating has been identified as a possible factor triggering binge eating in bulimia nervosa (BN) and binge eating disorder. Few studies considered emotional eating in patients with anorexia nervosa.MethodsThe present study evaluated the clinical correlates of emotional eating in 251 eating-disordered (EDs) subjects (70 AN restricting type, 71 AN binge eating/purging type, 110 BN purging type) and in a group of 89 healthy control subjects. Subjects were assessed by means of a clinical interview (Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) and several self-reported questionnaires, including the Emotional Eating Scale (EES).ResultsNo significant differences were found between the 3 EDs groups in terms of EES total score, and all patients with ED showed higher EES scores compared with control subjects. Emotional eating was associated with subjective binge eating in AN binge eating/purging type and with objective binge eating in patients with BN. Among patients with AN restricting type, emotional eating was associated with restraint, but this association was lost when controlling for fear of loss of control over eating, which was the principal determinant of restraint.ConclusionEmotional eating and fear of loss of control over eating are significantly associated with specific eating attitudes and behaviors, according to the different diagnoses. Emotional eating is a relevant psychopathologic dimension that deserves a careful investigation in both anorectic and bulimic patients.     

Health-related quality of life among adolescents with eating disorders

Objective

Health-related quality of life (HRQoL) is an emerging area of research in eating disorders (EDs) that has not been examined in adolescents in detail. The aim of the current study is to investigate HRQoL in an adolescent ED sample, examining the impact of ED symptoms on HRQoL.

Methods

Sixty-seven treatment-seeking adolescents (57 females) with anorexia nervosa (AN), bulimia nervosa (BN), or eating disorder not otherwise specified (EDNOS) completed self-report measures of HRQoL and ED symptoms.

Results

Participants reported poorer HRQoL in mental health domains than in physical health domains. Disordered attitudes, binge eating, and compensatory behaviors were associated with poorer mental health HRQoL, and body dissatisfaction was associated with poorer physical health HRQoL.

Conclusion

The current study assessed HRQoL among adolescents with EDs, finding several consistencies with the literature on adults with EDs. Future research should compare adolescents and adults with EDs on HRQoL.     

Association between 5HT2A receptor gene promoter region polymorphism and eating disorders in Japanese patients.

BACKGROUND: Evidence from family and twin studies suggests a genetic contribution to the etiology of eating disorders (EDs). Recently, researchers have reported genetic associations between the MspI polymorphism (-1438A/G) of the promoter region of the 5HT2A receptor gene and EDs; however, reports of evidence against these findings make the association controversial. METHODS: The authors examined the prevalence of the -1438A/G polymorphism of the 5HT2A receptor gene among 182 Japanese patients with EDs and 374 normal control subjects. Interactions of the association of this polymorphism with subtypes of anorexia nervosa (AN), bulimia nervosa (BN), and various clinical characteristics were also assessed. RESULTS: In contrast to previous studies reporting elevated A allele frequencies in patients with AN, the G allele had a significantly higher frequency in patients with BN but not in patients with AN, than in control subjects. Examination of the interactions revealed that the presence of the binge eating and/or purging behavior and comorbid borderline personality disorder (BPD) tended to be associated with increased frequency of the G allele. CONCLUSIONS: Though preliminary, these results can be interpreted as suggesting that the G allele of the 5HT2A receptor gene -1438A/G polymorphism may be associated with pathological features that EDs and BPD have in common, especially disinhibition in eating behavior and personality trait.     

Dysfunctional eating in the eating disorders.

Aberrant eating patterns in the eating disorders have been observed across various laboratory-based and clinical studies. It is now clear that problems in experiencing and expressing hunger, appetite, and satiety in anorexia and bulimia nervosa are likely to perpetuate the disorders once established. Whether problems in appetite regulation are primary or secondary to the development of the disorders is unknown. In studies examining indices of appetite regulation after treatment, there still remain significant levels of eating abnormality. This suggests that the main goals of treatment, including restoration of body weight in anorexia nervosa, abstaining from dieting in anorexia or bulimia nervosa, and reducing or abstaining from binge eating, do not correct some features of abnormal eating. The efficacy of nutritional counseling and specific nutritional management programs have been tested, and these seem to produce positive outcomes in improving eating behavior. Direct behavioral interventions to change eating patterns also have been examined, and these too seem to produce benefits that may be incorporated into CBT. Greater collaboration and cooperation between researchers and clinicians in addressing dysfunctional eating in the eating disorders will highlight improvements in treatment for identifiable eating abnormalities and will further the understanding of the human appetite system.     

Comorbidity of eating disorders and bipolar affective disorders

Eating disorders--anorexia nervosa, bulimia nervosa and eating disorders not otherwise specified (EDNOS) occur usually in young females. The significant pathogenic differences between patients who only restrict food, and patients with binge eating and compensatory behaviours, such as vomiting and purging were described. The prevalence of bipolar affective disorders--especially bipolar II and bipolar spectrum disorders (BS) may reach 5% in the general population. About half of the depressive episodes are associated with a "mild" bipolar disorder, and such a diagnosis is suggested by impulsivity and mood-instability. Previously, majority of research on the comorbidity between eating and affective disorders focused on depressive symptomatology, however difficulties in the reliable assessment of hypomania may obfuscate the estimation of the co-occurrence of eating disorders with BS. Epidemiological studies suggest the association between BS and eating disorders with binge episodes (bulimia nervosa, anorexia- bulimic type and EDNOS with binge episodes). Co-occurrence of such disorders with depressive symptoms probably suggests the diagnosis of BS, not recurrent depression. Bulimic behaviours, impulsivity and affective disorders might be related to the impairment of the serotonergic neurotransmission, which may result from the genetic vulnerability and early life trauma. Currently, the first-line pharmacological treatment of co-occurring eating disorders with binge episodes and BS are selective serotonin reuptake inhibitors. However in some cases, the use of mood-stabilising agents as monotherapy or in combination with serotonergic drugs may be helpful.     

Efficacy of topiramate in bulimia nervosa and binge-eating disorder: a systematic review

OBJECTIVE: The objective of this review was to establish the efficacy of topiramate as treatment for eating disorders associated with obesity. METHODS: We reviewed all five published controlled clinical trials that tested the efficacy of topiramate in treating bulimia nervosa (BN) or binge-eating disorder (BED). Two trials involving 128 patients studied topiramate efficacy in BN, and three trials (528 patients) studied patients with BED. Data on the number of participants, weeks of follow-up, dropouts, binge frequency and weight were extracted. RESULTS: Short-term treatment with topiramate is more effective than treatment with placebo in decreasing binge episodes per week (overall result: topiramate group: -5.0+/-0.6; placebo group: -3.3+/-1.2), binge days per week (topiramate group: -3.5+/-0.6; placebo group: -2.3+/-0.7) and corporal weight (topiramate group: -4.6+/-2.3; placebo group: -0.5+/-0.6) in both BN and BED. The high number of withdrawals and the small sample sizes in four of the five controlled clinical trials limit the generalizability of this result. CONCLUSION: Topiramate is effective in the short-term treatment of eating disorders associated with obesity. Additional studies are needed to prove its efficacy in the long term and to determine the optimal effective dose.     

Effectiveness of individualized,integrative outpatient treatment for females with anorexia nervosa and bulimia nervosa

ABSTRACT

The effectiveness of an individualized outpatient program was investigated in the treatment of bulimia nervosa (BN) and anorexia nervosa (AN). Participants included 151 females who received outpatient eating disorder treatment in the partial hospitalization program, the intensive outpatient program, or a combination of the two programs. Outcome measures included the Eating Disorder Inventory (EDI-2), Beck Depression Inventory (BDI-II), frequency of binge eating and purging, and mean body weight. Findings included significant increases in weight for the AN group, reductions in binge eating frequency for the BN group, and reductions in EDI-2 and BDI-II scores and purging frequency for both groups. This study provides preliminary support for the efficacy of a multimodal program for the treatment of both anorexia nervosa and bulimia nervosa.