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Clinical Treatment of Anorexia Nervosa
Merits More Attention by James Greenblatt, M.D.
Psychiatry has made tremendous strides in treating all major psychiatric illness with the development of new medications. Yet there is not one drug approved for the treatment of Anorexia Nervosa.
Anorexia Nervosa, a life-threatening eating disorder that results in fear of and avoidance of food, has the highest mortality rate of any psychiatric illness. More than 30 percent of patients with Anorexia Nervosa become chronically ill within 10 years. Ten percent die within 10 years and 20 percent die within 20 years. The risk of suicide and the number of hospital days needed for treatment are higher than for any other psychiatric illness.
The typical clinical protocol for Anorexia Nervosa is to prescribe antidepressants, even though there is no evidence that they help. The Journal of the American Medical Association, for example, published the results of a randomized, controlled trial showing no benefit from the use of Prozac.
We should do better than prescribing drugs for Anorexia Nervosa that don’t work. So what should be done?
Step One. Recognize Anorexia Nervosa as a serious illness. The National Institute of Mental Health estimates that 1% of women and adolescent girls have Anorexia Nervosa, and that more than 1,000 women die from Anorexia Nervosa annually. Males are also susceptible, but in much smaller numbers. Because people with Anorexia Nervosa do not receive nutrition necessary for good health, every organ system can be affected, resulting in major health issues, such as low blood pressure, slow heart rate, reduced bone density, dehydration, kidney failure and heart failure.
In most cases, individuals with Anorexia Nervosa also have co-occurring disorders, such as depression, anxiety, obsessive-compulsive disorder, substance abuse and bipolar disorder.
Some still think of this life-threatening illness as a schoolgirl fad. But Anorexia Nervosa is clearly a major illness and should be recognized as such.
Step Two. Identify characteristics that make a person susceptible to Anorexia Nervosa. Anorexia Nervosa is a complex disorder and many factors make a person susceptible to its onset, including genetic, biological, psychological and sociocultural factors. No single factor has been shown to be either necessary or sufficient to express the disorder.
A person’s temperament, which influences how a person interprets external events, can also have an impact. Research has demonstrated that temperament is genetically determined. Temperament characteristics common to those with Anorexia Nervosa include increased harm avoidance, decreased novelty seeking, and increased persistence.
Problems at birth may also indicate a predisposition toward Anorexia Nervosa. A Swedish study of 781 girls with Anorexia Nervosa found that premature birth increased the risk of Anorexia Nervosa three fold, while trauma at birth doubled the risk. Low birth weight, multiple birth and delivery with an instrument also increased the likelihood the individual would later develop Anorexia Nervosa.
A dislike of meat and other animal products may also be an early warning sign. A large percentage of patients with Anorexia Nervosa are vegetarians – not out of a moral or environmental commitment, but because they dislike the taste of animal products. A study of 45 Anorexia Nervosa patients being treated in an outpatient clinic found that 55 percent had abstained from meat for more than a year before the onset of Anorexia Nervosa. Their dislike of meat, usually against family wishes, began at an average age of 11.
Anorexia Nervosa often begins with dieting. Many people, both men and women, young and old, diet without becoming obsessed with their weight and developing Anorexia Nervosa. However, an individual who is already susceptible to Anorexia Nervosa may trigger the disorder by dieting.
Step Three. Begin treatment early. While Anorexia Nervosa can begin at almost any age, including a person’s senior years, it typically begins to manifest itself during puberty.
A study of 31,206 twins born between 1935 and 1958, published in the Archives of General Psychiatry in 2006, found that the onset of puberty brought on profound changes. There were no genetic factors in weight preoccupation and eating pathology in 11-year-old twins, but there was a 52 percent to 57 percent variance in eating pathology in 17-year-old twins.
At that age, individuals may show symptoms of Anorexia Nervosa, but often do not have all of the symptoms necessary to be classified as having Anorexia Nervosa. Even many adults with eating disorders fail to meet all of the criteria and, as a result, may not qualify for insurance coverage.
In a poster presented at the American Psychiatric Association in May 2007, of 165 patients with eating disorders, 147 were diagnosed with EDNOS, or “eating disorders not otherwise specified,” meaning they failed to meet all of the criteria necessary for a diagnosis of Anorexia Nervosa, bulimia or another recognized eating disorder.
If patients in the early stages of Anorexia Nervosa fail to qualify for insurance coverage, they may not seek treatment until their illness is more advanced. At that point, the disorder becomes more difficult and more costly to treat. Early treatment is more likely to succeed and can prevent the onset of co-occurring disorders.
Step Four. Use appropriate treatment options. Treatment of Anorexia Nervosa varies greatly, depending on the severity of the illness and “philosophy” of the treatment team. There are dramatically few randomized controlled treatment studies for Anorexia Nervosa.
A “continuum of care” model is ideal, as patients can move along a continuum of treatment options as progress is made or upon the first signs of relapse. Seriously ill patients require specialized inpatient eating disorder units where intensive medical management of weight restoration and nutritional rehabilitation is required.
Typically, patients requiring inpatient care have lost 15 to 20 percent of their normal weight, developed electrolyte abnormalities or become refractory to outpatient treatment, secondary to increased delusional thinking around food and body image. Less severe patients can be treated in a partial hospital program and those who are not in medical danger can be treated as outpatients with a multidisciplinary team approach.
A multifaceted treatment approach, including medical management, individualized therapy and psychoeducation, is most often recommended. If under 18, controlled studies have shown better outcome if family therapy is included.
Referenced EEG (rEEG), an innovative technology that has been used for eating disorder patients for over 10 years, provides psychiatrists with objective findings to guide the choice of medications. Using standard electroencephalographic equipment, rEEF provides an individualized report showing what medications have been used successfully on patients with similar neurophysiology.
The development of rEEG was based on EEG changes recorded with successful medication changes over 18 years. Thousands of patients are included in a database that enabled the definition of mathematical relationships for different medications and made possible a report of the likelihood that a patient with a given abnormality would respond to specific medications.
During the four years Walden Behavioral Care has used rEEG to guide medication choices, many patients have shown significant improvement. One patient, who previously had 30 years of multiple medication trials, saw her symptoms go away after taking medication prescribed based on rEEG! Many others have improved, with less eating disordered behavior and depressive symptoms, resulting in greater motivation for treatment.
Vitamins and minerals are rarely integrated into treatment beyond a multivitamin and calcium, and deficiencies are rarely studied, even though Anorexia Nervosa is characterized by self starvation.
As early as the 1970s, research suggested zinc deficiency may play a role in the development of Anorexia Nervosa. Symptoms of zinc deficiency include decreased appetite, weight loss, altered taste, depression and amenorrhea. Adolescents typically eat diets low in zinc and high in inhibitors of zinc absorption. Meat and fish are the best sources of zinc, and many plant and wheat products impair absorption of zinc.
Controlled research studies support the use of zinc in treating Anorexia Nervosa, so why aren’t zinc supplements a routine part of a multifaceted treatment program? While treatment guidelines in Canada, Australia and New Zealand recommend the use of zinc supplements, American Psychiatric Association guidelines and a position statement from the American Dietetic Association do not.
Other nutritional deficiencies are also prevalent in patients with eating disorders. Symptoms of vitamin B deficiencies overlap with many of the features of Anorexia Nervosa. Patients with Anorexia Nervosa also avoid fat intake for long periods, while scientific research and professional recognition highlight the critical role essential fatty acids (EFAs) play in brain function. The Omega-3 fatty acids, which play a central role in nerve cell membranes from early development through adulthood, cannot be manufactured by the human body and must be acquired through diet. Research supports the relationship between EFA-deficiency and many medical and psychiatric conditions, including depression, attention deficit hyperactivity disorder and bipolar disorder. A recent study of Anorexia Nervosa and Omega-3 supplementation showed improvement in patients given 1 gram of EFAs along with standard treatments.
Anorexia Nervosa has atypical onset in adolescence. Proper nutrition during adolescence may help prevent the onset of Anorexia Nervosa and will, of course, help prevent other illnesses. Nutrition is especially important during puberty, as adolescents typically gain 20 percent of their adult height, 45 percent to 50 percent of their peak bone mineral, and 50 percent of their adult weight and skeletal mass during this period.
Yet today’s diet is less than optimal for America’s adolescents. Typically:
50 percent of caloric intake of American children is obtained from added fat and sugar
20 percent to 24 percent of calories for children aged two through 19 comes from soft drinks!
Less than 15 percent of school children consume the recommended servings of fruit and less than 20 percent consume the recommended servings of vegetables.
It’s probably not coincidental that the incidence of Anorexia Nervosa has increased rapidly in recent years, as the American diet has deteriorated.
Anorexia Nervosa is, of course, a complex illness. More studies are needed, but we can make progress by following the steps outlined here.
James Greenblatt, M.D., is Chief Medical Officer of Walden Behavioral Care in Waltham, Mass. He can be reached at firstname.lastname@example.org.
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