The role of pharmacotherapy in anorexia nervosa and bulimia

The purpose of this article is to review the basic pharmacology and the role of drugs that are used to treat anorexia nervosa and bulimia. The pharmacological treatment of eating disorders is based upon theoretical principles. The theoretical models include: (a) an illness secondary to other psychiatric disorders, (b) a disorder in the hypothalamic control of food intake, (c) a disorder of hypothalamic endocrine regulation, (d) a syndrome secondary to depressive illness, and (e) a disorder in the hypothalamic regulation of food intake. Theoretical models a, b, and c govern the choice of drug therapy for anorexia nervosa, and models d and e govern the choice of drug therapy for bulimia. Drugs used to treat anorexia nervosa and bulimia include tricyclic antidepressants and lithium carbonate. Chlorpromazine, metoclopramide, cyproheptadine, and clomiphene citrate have also been prescribed for the treatment of anorexia nervosa. Monoamine oxidase inhibitors are commonly prescribed to treat bulimia. Fenfluramine has the potential to be of therapeutic value in patients with bulimia. Although drug therapy plays a limited role in the treatment of eating disorders, drugs are commonly prescribed. Therefore, the nutritionist should be familiar with the basic pharmacology and the side effects related to drug therapy.     

Suicide and attempted suicide in anorexia nervosa and bulimia nervosa

Suicide in anorexia nervosa and bulimia nervosa is a major cause of death. Risk factors for suicide and attempted suicide (which in many cases results in successful suicide) in anorexia nervosa include: purging type, chronic disease, and during treatment, obsessive symptoms and drug abuse, major depression, and for anorexia nervosa low body mass index (BMI) at presentation. In anorexia nervosa suicide has been considered the first cause of death and attempted suicide is a serious threat to these individuals. Data concerning suicide in bulimia nervosa has still scarce whereas attempted suicides are easily found in clinical histories of patients. No doubt suicidal behavior is underestimated amongst patients with anorexia nervosa and bulimia nervosa. An effort to reconcile with subject of suicide and a better evaluation of these patients' psychopathology should improve suicide prevention strategies amongst these individuals.     

Taste function in patients with anorexia nervosa and bulimia nervosa

The sensitivity to sucrose, sodium hydrochloride, tartrate, and quinine was examined by a filter paper disc method in patients with anorexia nervosa and with bulimia nervosa. There were 20 of the 23 anorexia patients and 11 of the 13 bulimic patients who showed hypogeusia. There were 12 of the 23 anorexia patients and 8 of the 13 bulimia patients who showed dysgeusia. Seven anorexia patients were restudied when the treatments produced a weight gain to more than 85% of normal body weight. Taste function had improved substantially in all but still was subnormal. Serum zinc, iron, and triiodothyronine levels in these patients were depressed; however, none of these levels correlated with the taste recognition scores or dysgeusia scores. In conclusion, patients with anorexia nervosa and bulimia nervosa showed hypogeusia and/or dysgeusia, although the etiology of the taste dysfunction in these patients remains to be determined. These findings should be considered in the implications for treating these patients.     

Cognitive style of patients with anorexia nervosa and bulimia nervosa

Nine female patients with anorexia nervosa and 7 female patients with bulimia nervosa were assessed on the Matching Familiar Figures Test (MFFT). This study found that subjects with bulimia nervosa responded more quickly than did the anorexic subjects. Results such as these suggest that not only are bulimic patients more behaviorally impulsive than anorexic patients, they are also more cognitively impulsive. Patients with anorexia nervosa in contrast seemed to display a reflective cognitive style. Extreme cognitive styles may contribute to resistance in treatment and/or relapse in anorexia or bulimia nervosa. © 1995 by John Wiley & Sons, Inc.     

The prevalence of anorexia nervosa and bulimia nervosa among freshman medical college students in China

This paper reports the results of a questionnaire survey administered to 509 Chinese college freshman (108 males, 401 females), in Chongqing and Shanghai. The response rate was 700%. Questions were constructed to elicit information which would allow identification of those respondents who would meet domestic (Chinese), DSM-III and DSM-III-R requirements for anorexia nervosa and bulimia. 1.1 % of the student population (1.7 % of females) met domestic and DSM-Ill-R for bulimia and I .3% of the student population (1.8% of males 1.2% of females) met DSM-Ill criteria for bulimia; however, none were binge eating and purging on a regular basis and none met diagnostic criteria for anorexia nervosa. © 1992 by /John Wiley & Sons, Inc.     

Drug use in women with anorexia and bulimia nervosa

Forty-two inpatient women with bulimia nervosa and 29 women with anorexia nervosa were surveyed regarding eating behavior, patterns of licit and illicit substance use, and relation between drug use and appetite. Substantial use of licit substances such as laxatives, diuretics, and emetics were reported in women with bulimia nervosa. In addition, alcohol and cigarette use were significantly more common in women with bulimia nervosa than anorexia nervosa. The majority of bulimic subjects reported that smoking decreased appetite, alcohol increased appetite, and laxatives had no effect on appetite. Analysis of temporal patterns of drug intake suggested that binging and purging as well as alcohol, cigarette, and laxative use were considerably more prevalent in the evening hours. We suggest that the high rates of drug use in women with bulimia nervosa may be related to effects of food deprivation associated with the disorder.     

Changes in creatinine clearance during treatment of anorexia nervosa and bulimia nervosa

The improvement in renal clearance of creatinine in anorexia nervosa patients during treatment has been attributed to the increase in body weight. The body weight and creatinine clearance of 72 anorexia nervosa and 10 bulimia nervosa patients were studied during inpatient treatment. The anorexia nervosa patients gained an average of 4.5 kg, while the body weight of the bulimia nervosa patients was unchanged. Both groups showed a similar increase in weight-corrected creatinine clearance. The increase in creatinine clearance of eating disorder patients is associated with the cessation of the abnormal weight-controlling behaviors rather than weight gain.     

Anorexia nervosa: A study of psychiatrists' and psychologists' opinions and practices

A structural questionnaire was used to determine the opinions of psychiatrists and psychologists regarding various aspects of anorexia nervosa. The results of the survey indicate that both professional groups agreed as to the many signs of anorexia nervosa but differed as to the significance of physical overactivity, anxiety related to food intake, and presence of additional psychological illness. There were more similarities than differences regarding precipitating events and therapeutic treatment of anorexia nervosa.     

Gastric inhibitory polypeptide (GIP) in anorexia nervosa

Simultaneous glucose, insulin, and gastric inhibitory polypeptide (GIP) responses to meal stimulation were measured in five anorexia nervosa patients, eight bulimia patients with a past history of anorexia nervosa, and twenty-two healthy subjects. Although basal levels of GIP were similar, anorexia nervosa patients had an early and significantly higher (p <.05) mean peak GIP response than controls or bulimics with past anorexia nervosa. Mean peak insulin levels in anorexia nervosa patients did not differ significantly from those of control or bulimia/past anorexia nervosa patients, although anorexia nervosa patients had a nonsignificantly prolonged elevation of serum insulin. Glucose responses were not significantly different among the various groups. The exaggerated CIP response to meal stimulation with no significant difference in insulin levels suggests that the usual association between insulin and GIP is altered in anorexia nervosa. This is apparently a state-dependent abnormality since GIP responses in bulimia patients with a history of anorexia nervosa do not differ from healthy subjects. Altered GIP responses may contribute to the gastric hypomotility and acid secretion changes previously reported in low-weight anorexia nervosa patients.     

Clinical and personality correlates of body size overestimation in anorexia nervosa and bulimia nervosa

A video camera technique was used to assess perceived actual and ideal size in patients with a restricting type of anorexia nervosa (n = 17), bulimia nervosa patients with previous anorexia (n = 23), bulimia nervosa patients with no previous anorexia (n = 24), phobic controls (n = 18), and normals (n = 33). Bulimic patients with previous anorexia demonstrated a significantly greater tendency to overestimate their actual body size (p <.05) than subjects in the restricting anorexic or control groups. Previously anorexic bulimics also demonstrated more overall clinical and personality disturbance than any of the other groups (p <.01). Body size overestimation and dissatisfaction were strongly associated with the duration and severity of the eating disturbance in previously anorexic bulimics but there were no clear relationships between clinical or personality disturbances and body size distortions in the restricting anorexic or never-anorexic bulimic groups. Results are discussed with respect to the importance of refining diagnostic criteria for subtypes of anorexia and bulimia nervosa. Multitrait-multimethod methodologies are recommended for purposes of elucidating “body image disturbance” and its importance in the etiology and maintenance of eating disorders.     

Racial and socioeconomic: Influences in anorexia nervosa and bulimia

Eight black and 120 white patients with anorexia nervosa or bulimia were compared with each other and with 21 black control patients. Biack and white patients with eating disorders were similar in demographic features (except for later age of onset in blacks), in clinical characteristics, and in course of illness. Both racial groups with eating disorders had a significantly higher socioeconomic status than control patients. A diagnosis of anorexia nervosa or bulimia can be confidently made independent of racial designation. Socioeconomic status appears to be a risk factor for development of anorexia nervosa or bulimia in both black and white populations.     

Phase 1 treatment for the chronic and previously treated anorexia. Bulimia nervosa patient

Treatment of anorexia nervosa/bulimia patients with a chronic course who previously were treated is given little attention in the literature. At the Uppsala University Hospital, a special program was developed for this category. It is assumed that successful therapy requires (1) a combination of therapeutic modalities, (2) a stepwise treatment, (3) a combination of anorexia nervosa and bulimia treatment principles, and (4) a treatment goal that is subjectively valid for the patient. In the present article, “Phase 1” is described. This involves teaching eating control through detailed diet and activity regimens supported by daily talk sessions, body-awareness therapy, and occupational therapy. “Phase 2” psychotherapy is thereby made possible. Results are promising in that a substantial proportion of patients were able to reach eating and weight goals not attained in previous treatments. Possible ways of improving results, the role of medical management, and implications for treatment of young patients are discussed.     

Excessive exercise in anorexia nervosa and bulimia nervosa: relation to eating characteristics and general psychopathology

OBJECTIVE: Excessive exercise is a well-known phenomenon in anorexia nervosa, but less is known about its role in bulimia nervosa. In addition, there is little evidence regarding the psychopathological processes that might act as predisposing, triggering, or maintaining factors for such exercise. The present study examined the presence of excessive exercise in different women with eating disorders, and its psychopathological correlates. METHODS: Case notes from 63 anorexia nervosa and 61 bulimia nervosa patients were examined. Two-way multivariate analyses of variance (diagnosis x use of excessive exercise) were used to determine the impact of the two factors upon eating characteristics (EAT-40 and BITE) and psychopathological symptoms (SCL-90-R). RESULTS: While high levels of depression were more likely among all patients who used excessive exercise, levels of anxiety and somatization were particularly high only among those anorexics who exercised excessively. DISCUSSION: Possible explanatory models are advanced to account for this pattern of findings, focusing on the possible use of exercise as an affect regulation strategy among anorexia nervosa patients. Further research is suggested to test and develop this model, and possible clinical implications are outlined.     

Body images in anorexia nervosa and bulimia nervosa

This study extends earlier research on body image disturbance in anorexia nervosa to the reactions of patients with bulimia nervosa. “Natural” procedures were employed, and normal comparison groups as well as those with anorexia nervosa or bulimia nervosa used adjective scales to rate “the self,” mirror images of themselves that were veridical, exaggerated for fatness or for thinness and adjusted to their ideal, and a television image they had adjusted to show how they feel and then how they think their body is. The different adjustments and ratings that were made in each condition question the validity of any single estimates of body size. Nevertheless, this multimethod approach to the cognitive and affective components of body image shows that those with anorexia nervosa and bulimia nervosa consistently emphasize their feelings of fatness.     

Participant recruitment for an anorexia nervosa treatment study

OBJECTIVE: To investigate the nature of differing recruitment rates for clinical treatment trials for anorexia nervosa and bulimia nervosa. METHODS: Recruitment rates from a study recruiting women partially recovered from anorexia nervosa were compared with the rates from two studies conducted at the same sites recruiting women with bulimia nervosa. RESULTS: At all sites in the anorexia study, the total number of contacts per month rose steadily over the first 2 years of the recruitment phase then decreased to near zero with the number of participants randomized to the study practically evaporating. In contrast, the bulimia studies screened a larger group of contacts and met monthly randomization goals in the time allotted for recruitment. Participants eligible for a study but with a barrier to participation occurred at a much higher rate in the anorexia study than in the bulimia studies. DISCUSSION: These results reveal a difficulty in planning recruitment from a small population such as partially recovered anorexics. A small population's total pool size diminishes faster than it is replenished, suggesting that future studies of anorexia nervosa may recruit more successfully from many sites in a short period rather than at a few sites over a long period.     

Perception of hunger and satiety induced by 2-deoxy-D-glucose in anorexia nervosa and bulimia nervosa

The effect of intracellular glucopenia induced by 2-deoxy-D-glucose (2-DG) on changes in hunger ratings, blood glucose, plasms cortisol, and prolactin levels were examined in six female patients with primary anorexia nervosa, three patients with bulimia nervosa, and six age-and sex-matched volunteers. In the normal subjects, hunger ratings obtained by the linear visual analog technique increased significantly at 60 minutes after 2-DG infusion and remained elevated. In Patients with anorexia nervosa, however, hunger ratins paradoxically decreased significantly at 90 minutes. In normal subjects, the ingestion of a 20-minute lunch relieved hunger, but neither the anorexic patients nor bulimic patients felt satiety even after food intake. These results suggest that the perception of hunger induced by 2-DG in anorexia nervosa and that of satiety in anorexia nervosa and bulimia nervosa are disturbed.     

The use of electroconvulsive therapy in patients with intractable anorexia nervosa

The history of the treatment of anorexia nervosa includes the majority of psychological and somatic therapies devised by psychiatrists, psychologists, and general physicians. We review the history of one of these treatments, electrical convulsive therapy (ECT), and discuss three patients treated with ECJ for primary anorexia nervosa. Two had a positive response to this treatment, one did not. She later responded favorably to a course of treatment with fluoxetine. © 1993 by John Wiley & Sons, Inc.     

Six-year course and outcome of anorexia nervosa.

OBJECTIVE: Since there are discrepant findings in the literature, we studied the longer-term course in a large sample of 103 DSM-IV anorexia nervosa (AN) patients. METHOD: Assessments were made at four points of time: beginning of therapy, end of therapy, 2-year follow-up, and 6-year follow-up. Self-rating scales as well as expert-rating interview data were used. Eating disorder-specific and general psychopathology were assessed. These data were also compared with data on the 6-year course of patients with bulimia nervosa and binge eating disorder, respectively, who were treated at the same institution at about the same time. RESULTS: The participation rate at the two follow-ups was high (97.9% of those alive). The general pattern of results over time of those alive at 6-year follow-up was as follows: substantial improvement during therapy, moderate (in many instances nonsignificant) decline during the first 2 years posttreatment, and further improvement from 3 to 6 years posttreatment. At the time of the 6-year follow-up, 26.8% had AN, 9. 9% had bulimia nervosa-purging type (BN-P), 2.0% were classified as eating disorder not otherwise specified (ED-NOS), all diagnosed according to DSM-IV criteria; more than one half (55.4%) showed no major DSM-IV eating disorder. Based on an operationalized global outcome score at 6-year follow-up, 34.7% had a good outcome, 38.6% an intermediate outcome, 20.8% a poor outcome, and 6 of 101 persons (5.9%) were deceased. Body mass index was 17.9 +/- 2.8 at the 6-year follow-up; amenorrhea was still found in 23.9%. DISCUSSION: In comparison to samples with bulimia nervosa or binge eating disorder, the 6-year course of anorexia nervosa was less favorable. Mortality was rather high and symptomatic recovery protracted; predictors of unfavorable 6-year course were the presence of binges during 4 weeks before index treatment, psychiatric comorbidity, and low body weight at discharge from index treatment.     

Body shape perception in bulimia and anorexia nervosa

Nineteen female patients with bulimia and thirty-one with anorexia nervosa were studied using a distorting lens technique. Both groups overestimated their actual body shapes and the bulimia patients desired to be much thinner than they were. These findings are discussed in relation to the literature on the treatment of these disorders.