Chapter 5

Treatment of Eating Disorders

Eating disorders are most successfully treated when diagnosed early. Unfortunately, even when family members confront the ill person about his or her behavior, or physicians make a diagnosis, individuals with eating disorders may deny that they have a problem. Thus, people with anorexia may not receive medical or psychological attention until they have already become dangerously thin and malnourished. People with bulimia are often normal weight and are able to hide their illness from others for years. Eating disorders in males may be overlooked because anorexia and bulimia are relatively rare in boys and men. Consequently, getting—and keeping—people with these disorders into treatment can be extremely difficult.

In any case, it cannot be overemphasized how important treatment is—the sooner, the better. The longer abnormal eating behaviors persist, the more difficult it is to overcome the disorder and its effects on the body. In some cases, long-term treatment may be required. Families and friends offering support and encouragement can play an important role in the success of the treatment program.

Eating disorders are treatable, and people do recover from them. Recovery, however, is more than just the disappearance of starving, stuffing, and purging. To be lasting, it must include establishment of healthy weight and healthy eating patterns and resolution of the medical, psychological, social, and family problems that contributed to the eating disorder in the first place. Effective treatment includes several elements.

Hospitalization for weight gain and to manage suicide risk. Provides structure so eating patterns, bodily functions, and daily schedules can be stabilized. Hospitalization is often necessary when weight loss is extreme, when bingeing and purging are out of control, when there are related medical problems, when there is suicide risk, and when outpatient treatment has failed.

Medication to relieve depression and anxiety.

Dental work to repair damage and minimize future problems.

Individual psychotherapy to develop healthy, effective ways of solving problems and taking control.

Group therapy to build satisfying relationships; to learn how to express needs and feelings effectively.

Family therapy to change old patterns and create new, more satisfying, ways of communicating.

Nutritional counseling to debunk food myths and provide information about healthy eating.

Support groups to provide peer support. (Note: Support groups by themselves are not sufficient treatment for an eating disorder. To be effective, they should be integrated into a comprehensive treatment plan.)

If an eating disorder is suspected, particularly if it involves weight loss, the first step is a complete physical examination to rule out any other illnesses. Once an eating disorder is diagnosed, the clinician must determine whether the patient is in immediate medical danger and requires hospitalization. While most patients can be treated as outpatients, some need hospital care.

Conditions warranting hospitalization include excessive and rapid weight loss, serious metabolic disturbances, clinical depression or risk of suicide, severe binge eating and purging, or psychosis.

The complex interaction of emotional and physiological problems in eating disorders calls for a comprehensive treatment plan, involving a variety of experts and approaches. Ideally, the treatment team includes an internist, a nutritionist, an individual psychotherapist, a group and family psychotherapist, and a psychopharmacologist_someone who is knowledgeable about psychoactive medications useful in treating these disorders.

To help those with eating disorders deal with their illness and underlying emotional issues, some form of psychotherapy is usually needed. A psychiatrist, psychologist, or other mental health professional meets with the patient individually and provides ongoing emotional support, while the patient begins to understand and cope with the illness. Group therapy, in which people share their experiences with others who have similar problems, has been especially effective for individuals with bulimia.

Use of individual psychotherapy, family therapy and cognitive-behavioral therapy—a form of psychotherapy that teaches patients how to change abnormal thoughts and behavior—is often the most productive. Cognitive-behavior therapists focus on changing eating behaviors, usually by rewarding or modeling wanted behavior. These therapists also help patients work to change the distorted and rigid thinking patterns associated with eating disorders.

NIMH-supported scientists have examined the effectiveness of combining psychotherapy and medications. In a recent study of bulimia, researchers found that both intensive group therapy and antidepressant medications, combined or alone, benefited patients. In another study bulimia, the combined use of cognitive-behavioral therapy and antidepressant medications was most beneficial. The combination treatment was particularly effective in preventing relapse once medications were discontinued. For patients with binge eating disorder, cognitive-behavioral therapy and antidepressant medications may also prove to be useful.

Antidepressant medications commonly used to treat bulimia include desipramine, imipramine, and fluoxetine. For anorexia, preliminary evidence shows that some antidepressant medications may be effective when combined with other forms of treatment. Fluoxetine has also been useful in treating some patients with binge eating disorder. These antidepressants may also treat any co-occurring depression.

The efforts of mental health professionals need to be combined with those of other health professionals to obtain the best treatment. Physicians treat any medical complications, and nutritionists advise on diet and eating regimens. The challenge of treating eating disorders is made more difficult by the metabolic changes associated with them. Just to maintain a stable weight, individuals with anorexia may actually have to consume more calories than someone of similar weight and age without an eating disorder.

This information is important for patients and the clinicians who treat them. Consuming calories is exactly what the person with anorexia wishes to avoid, yet must do to regain the weight necessary for recovery. In contrast, some normal weight people with bulimia may gain excess weight if they consume the number of calories required to maintain normal weight in others of similar size and age.

ANTIDEPRESSANT MEDICATION IN THE TREATMENT OF EATING DISORDERS

For Bulimia Nervosa

How long have antidepressants been used to treat bulimia?

In the early 1980's, researchers found that antidepressant medication lessened binges, at least short term, in patients with bulimia. The group at Harvard used one type medication, while the one at Columbia used another. Both categories of antidepressants, as well as many others that were subsequently tried, proved effective.

How many kinds of antidepressants are there?

While there are dozens of different antidepressants on the market, they fall into four general categories:

1. MAOIs (MonoAmine Oxidase Inhibitors)

Example: Nardil (phenelzine)

Highly effective, especially for atypical depression and panic attacks, but require careful avoidance of various foods and medications.

2. Tricyclics

Examples: Elavil (amitriptyline) and Tofranil (imipramine); Norpramin (desipramine); and Pamelor (nortriptyline); Anafranil (clomipramine)

Elavil and Tofranil are sedating and associated with dry mouth and constipation. This is less of a problem with Norpramin and Pamelor. Anafranil is used for obsessive-compulsive disorder. All interact with alcohol and have potentially lethal cardiac effects in overdoses. Dosage is monitored by blood test.

3. SSRIs (Selective Serotonin Reuptake Inhibitors)

Examples: Prozac (fluoxetine) and Zoloft (sertraline)

Energizing rather than sedating. Minimal effect on heart and blood pressure. Relatively safe with alcohol or overdose.

4. Miscellaneous: Desyrel (trazodone); Wellbutrin (bupropion) Each has its own profile depending on chemical structure.

Why do antidepressants help bulimia?

Initially, some felt that if antidepressants helped bulimia, then bulimia must be a symptom of depression. Studies were subsequently done treating bulimic patients who were not depressed (most bulimics are depressed, but some are not). Non-depressed bulimics showed the same reduction in binges on antidepressant as bulimics who were also depressed.

How common is a response?

Studies of many antidepressants show 50-90% of patients with bulimia binge less on antidepressants. This is consistent with the fact that about 70% of depressed patients respond to any single medication. Two things are important to remember: First, some patients will respond to one kind of antidepressant and not another. Others may be just the opposite. To get the best response to medication, it is sometimes necessary to try several drugs or to combine them. In addition, an adequate dose must be used, and recommended doses for eating disorders may be higher than those used for depression alone.

Are antidepressants a cure for bulimia?

Although most patients binge less on antidepressants, only a minority become totally free of binges from medication alone. In addition, most studies are short-term. So a response is highly likely at 8-12 weeks, but longer-term studies suggest that symptoms may continue even though they are lessened, or relapse after stopping temporarily, if medication is the only treatment.

Antidepressants do not keep you from bingeing if you wish to; they facilitate binge control by making the urge to binge less intense and more manageable.

What are the advantages of using antidepressant medication?

Antidepressants may enable patients to lessen or stop bingeing. In addition, they lessen depression and may improve mood, energy, hopelessness, sleep. Certain drugs like Prozac may also lessen plaguing preoccupation with food and weight or obsession with exercise. This can help patients feel and function better, and may facilitate progress in therapy and with nutritional counseling.

What are the disadvantages of using antidepressants?

All medications have side effects. All cost money (some of the newer ones are quite expensive) and require monitoring by an M.D. Some are followed by blood tests. None has been proven safe during pregnancy. An occasional person will have an allergic rash on any drug, and most antidepressants lower the seizure threshold in patients with epilepsy.

What about the risk of addiction?

Antidepressants are not addicting. For drugs to be addicting, they need to produce an immediate rush of relief. Antidepressants take 4-6 weeks to have full effect, and you generally don't feel like you are on anything. In fact, many patients make the mistake of stopping their medication because, although they see that they are improved, they don't feel like they are on anything and don't realize that the medication is playing an important role.

Antidepressants can be used with safety even in recovering alcoholics and drug addicts. In fact, some studies suggest that alcoholics who remain depressed after they are sober may have a lower relapse rate if appropriately treated with antidepressants.

Why is Prozac so popular?

Prozac (fluoxetine) is the No. 1 antidepressant in this country for many reasons.

1. Safety Prozac is safer than many other antidepressants. MAO inhibitors may cause a severe or fatal reaction if patients eat certain forbidden foods. Tricyclics are fatal in overdoses, interact with alcohol, and aggravate the cardiac dangers of low potassium (which bulimics are prone to).

2. Effectiveness In addition to lessening the urge to binge and lessening depression, many patients feel less overwhelmed, overreact less and feel more like their old selves on Prozac. It also lessens obsessionalism, including the preoccupation with food, weight and exercise that annoys many patients.

3. Simplicity Prozac is managed clinically and does not require monitoring of blood levels. It can be taken once a day, though it may be divided between breakfast and lunch. Doses from one to four 20 mg. pills daily are usual. One to two is typical for depression, three daily is recommended for bulimia, four daily for obsessive-compulsive disorder.

4. Compliance Prozac has a high rate of acceptability to patients. It is energizing rather than sedating, and patients do not feel "drugged" (many actually feel "more like themselves"). Other side effects tend to be mild and short-lived. It does not cause the dry mouth and constipation that bothers many patients on tricyclics. There are no dietary restrictions, no interaction with alcohol, and few drug interactions (some psychiatric medications like tricyclics and lithium require dose changes when combined with Prozac. MAO inhibitors must be stopped for two to three weeks prior to beginning Prozac, and Prozac must be stopped for six weeks prior to beginning MAO inhibitors; they can be lethal together).

Many eating disorder patients fear medication because of potential weight gain. Prozac has weight loss as a side effect, easing this fear.

If medication helps, must it be taken forever?

For most patients, medication is a transitional vehicle: it can help them feel better and be less symptomatic while they are making progress in other ways. Therapy, new eating habits and different life situations help patients get to a place in their lives when they may no longer require medication.

Studies have suggested that less than six months of medication is too little. We know the relapse rate in bulimia is high for a year after the last binge and stays high as long as patients yearn to be thinner. For this reason, patients are encouraged to expect to continue medication for a minimum of a year or two. For students tapering off medication during a summer vacation is recommended.

Which treatment for bulimia is best?

Two recent studies evaluating medication and cognitive behavioral therapy found that each had a short term benefit, but medication and therapy combined worked better than either alone. Another study added medication to group therapy and found that patients felt much less depressed with the combination.

For Anorexia Nervosa

Can medication help anorexic patients?

No medication has been proven to facilitate weight gain in anorexia. However, a study at NIH and the experience of many clinicians have suggested it may be useful when added to a complete program of therapy and nutritional counseling. Another fascinating study evaluated anorexics brought up to normal weight in the hospital and discharged with comprehensive treatment. Half were also given Prozac, while half received a placebo. The patients on Prozac had a much lower relapse then those given placebo.

Does that mean anorexia is related to depression?

Some anorexic patients do have a history of depression, and healthy people who are starved also become depressed. However, it looks as though the response of anorexia to medication may have to do with its overlap, in symptoms and brain chemistry, with obsessive-compulsive disorder.

Will any antidepressant help anorexia?

Although virtually every antidepressant studied seems helpful in bulimia, so far only Prozac has been shown (in the still preliminary way described above) to be helpful in anorexia nervosa.

For Compulsive Overeaters

If compulsive overeaters aren't thin like anorexics and don't purge like bulimics, do they have an eating disorder?

The upcoming diagnostic manual (DSM IV) is expected to have a new category: Binge Eating Disorder. This will be the medical equivalent of compulsive overeater. These patients binge but do not purge, therefore most are overweight. They tend to fail traditional weight control programs, which emphasize restrictive eating and may actually aggravate binges. Many feel depressed, or have a history of depression or other psychological problems in themselves or their family.

What treatment helps compulsive overeaters?

Exciting initial studies show non-purging binge eaters have the same high rate of benefit from antidepressants as bulimics. Medication appears to have the same benefits in lessening binges and improving mood as in bulimia.

In addition, compulsive overeaters may benefit from psychotherapy, and also from behavioral strategies which focus on binge management.

Courtesy of

Diane Mickley, MD, FACP September, 1992

Dr. Mickley is President of American Anorexia and Bulimia Association and Director of Wilkins Center for Eating Disorders, Greenwich, CT.

Further reading

Dowling, Colette You Mean I Don't Have to Feel This Way (Charles Scribner and Sons, 1991)

Jonas, Jeffrey All You Need to Know About Prozac (Bantam, 1990)

Pope, Harrison and Hudson, James New Hope for Binge Eaters (Harper and Row, 1984)

Continue to the next chapter.