Living With Food: The Science Supporting Eating Disorder Treatment

Medication may be part of successful treatment for bulimia nervosa. In multiple studies, treatment with antidepressants has been shown to be moderately effective in reducing the binge/purge cycle of an individual with bulimia nervosa. Trials have shown that antidepressants are superior to placebos in diminishing overeating, decreasing self-induced vomiting, and increasing the sense of control that someone has over their eating. Other studies show the response for those with bulimia to be similar to the rate of response with depression. Since it takes approximately two weeks to observe changes in depression with medication, it is implied that within two weeks some benefit may be seen in those with bulimia as well. Large scale evaluation of the studies of bulimia suggest that high doses of fluoxetine, generally within the range of 60 mg a day, has been optimum for reduction of behaviors and improvement of sense of control. In general, the rate of response to antidepressant medications, in particular fluoxetine, has been shown to be approximately 50%. To date, no consistent predictors of response have been identified. That is, a level of depression prior to treatment does not predict how well these will work with bulimia, even though they may be indicated for depression.

Pharmacotherapy (the use of medication) is in general only minimally helpful for patients with anorexia nervosa. There are no studies demonstrating that any medication leads to recovery from anorexia. Many medications have been tried, including Selective Serotonin Reuptake Inhibitors (Prozac, Zoloft, Celexa, Lexapro) lithium, marijuana, Clonidine, Reglan, Propulsid, and Naltrexone, but none have been shown to be effective. The atypical antipsychotic medications (Zyprexa, Seroquel, Risperdol, Abilify) have been utilized in several trials for anorexia. They have not been shown to result in recovery.

Benzodiazepines, which are primarily used to target anxiety. Anxiety disorders may be comorbid with anorexia as high as 50% of the time, and the process of refeeding often increases anxiety as well. In these situations as part of the overall treatment plan, benzodiazepines (Ativan, Xanax, Kolonopin) may be useful. These medications are potentially addictive and may cause physiological dependence. Therefore, although they have the potential to be helpful, one must be cautious when taking these medications.
1. The atypical antipsychotics have also been shown to have value for some patients with anorexia. These can be helpful for patients whose eating disorder has aspects of obsessive compulsive disorder or delusional thinking. They may also be prescribed for clients whose anxiety or agitation around food issues may be so profound that they must be utilized for the client to have the ability to engage in other treatment. There are concerns about these medications causing weight gain due to overeating in some patients. To date this has not been shown to be the usual experience of patients with anorexia. We do not use these medications to facilitate weight gain.

By Dr. Jorey Friedman Beegun and Dr. Mark Warren

In Family Based Treatment (also known as the Maudsley method), parents play an active role in refeeding their child with the goal of restoring their child's weight to a range that is appropriate for their age, height and optimal medical and psychiatric functioning (as determined by a team of professionals and tailored specifically to the child). Once that has occurred, the parents gradually return control of eating back to the adolescent in a manner that stabilizes weight and behavior and allows for a focus on adolescent developmental issues that are often thrown off track by the illness.

Phase I of the Maudsley method in treating anorexia involves a shift of total control of eating from child to parents during which time the parents are responsible for making all choices surrounding food and re-feeding the adolescent. This first phase of treatment is critical because of need for the child to be gaining weight during a time in which their brain is malnourished and the fear of weight gain is acute. Given that many of the thoughts associated with anorexia nervosa are side effects of malnourishment itself, having an individual therapist or family member try to "convince" the adolescent to eat and gain weight is not successful and has no empirical support. What their brain needs is food and Phase I coaches the parent on providing their child the medicine (food) they need.

Phase II commences when a child has been successfully re-fed and parents believe that the child is ready to attempt to re-gain some control over their eating and food choices. Phase II extends from the very first collaborative moment around eating between the parents and child until the point where the child is able to successfully feed him or herself on a regular basis. This does not mean that the child will have no eating disordered thoughts, feelings, or body image issues as the time in which is takes for these to diminish or dissolve entirely is different for each child. However, the child's ability to tolerate and process these feelings is such that they can be working on eating independently in a gradual fashion.  Thoughts, feelings, and body image can be successfully addressed in phase III when normal teenage issues move into the forefront.

Phase III begins when the adolescent is able to maintain appropriate body weight and restriction has stopped. The focus shifts to an exploration of how the eating disorder has impacted the formation of a healthy adolescent identity and works to help both the parents and adolescent get back on track in terms of supporting age-appropriate developmental tasks.

It is important to note that the there are differences between the phases in FBT for those struggling with Bulimia Nervosa and Eating Disorder, Not Otherwise Specified given that those adolescents are often weight-restored. The Maudsley Method is more collaborative with these diagnoses, the degree of which is clinically determined during the initial Maudsley sessions. 

Contributions by Sarah Emerman

As we enter the new year, the new federal mental health parity legislation goes into effect. While this legislation is a landmark in many ways, at this time it does not guarantee that people who suffer from eating disorders will be able to access treatment without discrimination by insurance companies and state rules/regulations.

For all of us in the eating disorder community, a top priority must be full parity for eating disorder treatment in every state. At present time, Ohio limits mental health parity to seven diagnoses. It does not specify eating disorders as one of those diagnoses. It is a goal of CCED to make the legislature aware and to assist advocates, patients, family members, and friends of those with eating disorders to encourage the state of Ohio to acknowledge the biological basis of eating disorders, the effectiveness of evidenced based care, and the necessity for all insurance companies to provide parity coverage for eating disorder diagnoses. Please join us in this crucial step towards helping those with eating disorders achieve recovery and a fullness for their lives in this new year. 

Check out the following websites to learn more about the legislation surrounding mental health parity and eating disorders: 

http://www.edadvocatesofohio.com/Site/State_Legislation.html

http://www.freedfoundation.org/about.php

http://www.eatingdisorderscoalition.org/summary-legislation.htm

Next week: What are the phases of Maudsley?

Contributions by Sarah Emerman 

According to the standards of the American Psychiatric Association there are five separate levels of care for eating disorder treatment. In terms of increasing intensity, these levels of care include: outpatient, intensive outpatient, full day treatment/partial hospitalization, residential treatment and inpatient hospitalization. An evaluation for appropriate level of care is the most important initial step in eating disorder treatment. Without receiving treatment at an appropriate level of care, the chances of successful treatment are significantly reduced.

It is critically important when beginning treatment or meeting with a provider for the first time that the assessment includes data to decide what the appropriate level of care is. This data should include: medical status, sucidiality, body weight as a percent of healthy body weight, motivation to recover, comorbid disorders, structure needed for treatment, ability to control impulsive behaviors, lethality/dangerousness of behaviors, environmental stressors, and geographic availability.

Outpatient care is generally indicated for a medically stable patient without suicidality, whose percent of ideal body weight is generally greater than 85%, with fair to good motivation. The client must be self-sufficient in their need for structure, able to manage their behaviors, and have an adequate support system.

Intensive outpatient programs are indicated when percent of ideal body weight is higher than 80%, and there is fair motivation. This level of care is appropriate when the client needs some meal support and when mild external structure will produce significant behavioral change.

Day treatment/partial hospitalization is indicated for patients when percent of ideal body weight is higher than 80%, with lower motivation, who may be preoccupied with intrusive thoughts and needs significantly higher external structure. This level of care provides a much greater level of meal support and structure to patients.

Residential care is generally indicated when a patient needs supervision for all meals, whose percent of ideal body weight is less than 85%, and requires a fulltime structured environment to reduce behaviors and increase medical stability.

Inpatient hospitalization is generally indicated for patients requiring medial stabilization, who may be experiencing low motivation and may have an existing psychiatric disorder that requires hospitalization and full time supervision. When medical stability is as risk all other criteria must take a backseat until stability is achieved. Once medically stable, other treatment decisions can be made.

Many people searching for eating disorder treatment are naturally unclear as to what level of care they initially need. This is particularly true when deciding between day treatment and residential programs, as they have similar criteria for admission and are both quite life interrupting. There are a number of excellent residential programs with whom we work and refer to. In general, day treatment should be attempted prior to residential treatment. There are a number of reasons for this including: the preference for a least restrictive environment, the ability to work with partial motivation at both levels of care, presence of increased structure at both levels of care, and the ability to stay at home while in treatment. Additionally, the importance of generalizing skills learned in treatment to ones home life is a critical issue for all patients with eating disorders. When residential is indicated, it often must be followed by a day treatment program to practice using acquired skills in a real life setting. 

Next week: What is compulsive exercise?  

Contributions by Sarah Emerman