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.

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 

One of the complications with treating eating disorders is that the illness itself causes distortions and difficulties with accepting the need for treatment. Effective therapy for eating disorders involves finding the motivation for change and working with your treatment team to make change happen. If you are in therapy for an eating disorder and have not yet found the reasons and motivations you need to get healthy, then it is unlikely that you will get better. Effective therapy therefore begins with developing the motivation to change, the commitment to doing the extraordinarily hard work ahead, and the orientation to what effective care will be for you. For treatment to be successful, these pieces must be in place.