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 Beyond the Basics – New Approaches to Treatment of Anorexia Nervosa by James Greenblatt, M.D.

Anorexia Nervosa is a serious and potential life threatening disorder that usually begins during adolescence.  Anorexia Nervosa is characterized by intense fear of gaining weight, weight loss, distorted body image and amenorrhea. 

Anorexia Nervosa was once considered a disorder of choice and the result of disturbed family relationships.  Since adolescence is the typical age of onset for Anorexia Nervosa, problems with adolescent development are considered core features for the onset of Anorexia Nervosa.  Psychological theories have described Anorexia Nervosa as a defense against the emergence of sexual development, difficulty negotiating separation from parents and enmeshed family dynamics.  These and other “psychological” theories are difficult to prove and do not account for new biological research.  Recent research now suggests a substantial influence of genetic factors in the development of Eating Disorders.  In a large study with over 31,000 twins, genetics accounted for the majority of the risk to develop Anorexia Nervosa.

Patients with Anorexia Nervosa are some of the most challenging and complex patients to treat.  Co-occurring psychiatric and substance abuse disorders are common in patients with Anorexia Nervosa.  Greater than eighty percent of patients with Anorexia Nervosa have other coexisting psychiatric disorders.  Depression, Anxiety, Personality disorders, Attention Deficit Disorder, Obsessive Compulsive Disorder and Bipolar Disorder are common psychiatric conditions complicating the treatment for patients with Anorexia Nervosa.

Current Treatment Options
The treatment for patients with Anorexia Nervosa varies greatly depending on the severity of the illness and “philosophy” of the treatment team.  A continuum of Care model is ideal as patients can move along a continuum of treatment options as progress is made or 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.  Typical patients requiring inpatient level of care may have lost 15-20% from 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 is most often recommended for the treatment of Anorexia Nervosa.  This approach would include medical management, individualized therapy, psychoeducation and if under 18, controlled studies have shown better outcome if family therapy is included.  There are dramatically few randomized controlled treatment studies for Anorexia Nervosa.  Cognitive Behavioral Therapy (CBT) can be used in both inpatient and outpatient settings.  This type of treatment requires special training and has limited efficacy in severely malnourished patients with multiple co-morbid psychiatric conditions.  A recent study published in American Journal of Psychiatry actually demonstrated that supportive therapy was superior to Cognitive Therapy in the treatment of Anorexia Nervosa.

Medical Management
The medical management of Anorexia Nervosa is extremely limited with currently no FDA approved medications.  Cyproheptadine (Periactin) an antihistamine drug has been shown to facilitate weight gain and for some patients reduce symptoms of depression.  There is no evidence that Antidepressants effect the outcome of Anorexia Nervosa.  Two recent articles have definitively challenged previous thoughts concerning the use of SSRI Antidepressants including Prozac, Zoloft and Paxil in the treatment of Anorexia Nervosa.  In an article published this year in the Journal of the American Medical Association, researchers failed to demonstrate any benefit in the treatment of Anorexia Nervosa in a randomized controlled trial of the antidepressant Prozac.  Antidepressant medications continue to be prescribed for up to 60% of Anorexia Nervosa patients despite no supported benefits!  More recently, the atypical antipsychotics including Olanzapine (Zyprexa) and Risperidone (Risperdal) have been shown to be effective in facilitating weight restoration and reducing the anxiety and delusional thoughts associated with treatment failures.  Controlled trials of these medications are currently being investigated.

New Approaches to Treatment

Referenced EEG
Referenced EEG (rEEG) is an innovative new technology that has been used for Eating Disorder patients for over ten years.  Referenced EEG is a technology that provides psychiatrists with objective findings to guide the choice of medications.  Referenced EEG utilizes standard electroencephalographic equipment measuring the patient in a resting state.  Referenced EEG provides psychiatrists with an individualized report that shows what medications have been successfully used with patients with similar neurophysiology.  Over the course of eighteen years, the development of Referenced EEG was based on EEG changes recorded with successful medication changes.  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.  Without adequate research supporting medication choices in Anorexia Nervosa, Referenced EEG reduces the trial and error approach to psychopharmacology. 

Referenced EEG has been standard practice at the Monte Nido Treatment Center, a residential program in California for patients with Eating Disorders.  Over 150 patients at Monte Nido have utilized an rEEG to determine medication sensitivities.  In a controlled trial of over eighty patients treated at Monte Nido, 80% of Anorexia Nervosa patients responded positively to the medications prescribed based on Referenced EEG results.  Walden Behavioral Care has used Referenced EEG over the past year.  Many treatment refractory Eating Disorder patients have shown significant improvement with the recommendations for medicines.  One patient stopped her symptoms after 30 years of multiple medication trials!  Many patients have seen improvement in Eating Disorder behaviors and depressive symptoms resulting in better participation and motivation for treatment.  Referenced EEG is an exciting technology that should minimize the often frustrating experiences many patients with Eating Disorders have with medication trials. 

Targeted Nutrition Therapy
Anorexia Nervosa is characterized by severe weight loss from self starvation yet signs or symptoms of vitamin and mineral deficiencies are rarely studied or integrated into treatment.  Patients with Anorexia Nervosa are profoundly malnourished although it is rare to find nutrient recommendations beyond a “multivitamin” and calcium. 

Research from as early as the 1970’s has suggested Zinc deficiency may play a role in the development of Anorexia Nervosa.  The signs of symptoms of zinc deficiency include decreased appetite, weight loss, altered taste, depression and amenorrhea.  Zinc is one of the most prevalent trace elements found in the brain.  Meat and fish are the best sources of zinc and many plant and wheat products impair absorption of zinc.  Adolescents are typically eating diets low in zinc and high in inhibitors of the absorption of zinc!  Controlled research studies have supported the use of zinc in the treatment of Anorexia Nervosa, yet the medical community has been slow to integrate zinc therapy as a component of a multifaceted treatment program.  Other nutritional deficiencies are prevalent in patients with Eating Disorders.  The symptoms of B Vitamin deficiencies also overlap with many of the features of Anorexia Nervosa.  There is now scientific research and professional recognition of the critical role that essential fatty acids play in brain function.  Patients with Anorexia Nervosa avoid fat intake for long periods of time with significant consequences for brain function.  The Omega-3 fatty acids found primarily in fish can not be manufactured by the human body and must be acquired through the diet.  These Omega-3 fatty acids play a central role in nerve cell membranes from early development through adulthood.  Research has supported the relationship between EFA deficiency and many medical and psychiatric conditions.  Depression, Attention Deficit Hyperactivity Disorder and Bipolar Disorders are all thought to be related to Essential Fatty Acid deficiencies.  A recent study of Anorexia Nervosa and Omega-3 supplementation showed improvement in patients supplemented with 1 gram of Essential Fatty Acids in addition to standard treatments.

Summary
Although cultural attitudes toward thinness and adolescent developmental issues have relevance to the psychopathology of Anorexia Nervosa, they are unlikely to be sufficient to account for the pathogenesis of these disorders.  A majority of young women diet, yet only a small fraction develop eating disorders.  Scientific research including family, twin and molecular genetic studies support substantial genetic influences on the development of Anorexia Nervosa.  As there are multiple factors contributing to the development of Anorexia Nervosa, treatment should address as many variables as possible.  Anorexia Nervosa is characterized by prolonged periods of malnutrition and targeted nutritional repletion is critical for recovery.  The goal of Eating Disorder treatment is to appreciate the unique genetic and psychological complexity of each individual.  As science and technology evolve, new treatment approaches like Referenced EEG and targeted nutritional therapy bring hope for the future. 

 

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