Treating anorexia nervosa requires multifocused approach

LAS VEGAS – Patients with anorexia nervosa rank among the most difficult to manage because of their resistance to treatment, according to Dr. Katherine A. Halmi.

"Patients with this disorder characteristically do not wish to be treated; they are terrified to give up their illness," Dr. Halmi, professor emerita of psychiatry at Weill Cornell Medical College, New York, said at the annual psychopharmacology update held by the Nevada Psychiatric Association. "They know the diagnostic criteria better than most clinicians do. If you ask them, are you afraid of gaining weight? Many of them will say, ‘No, I don’t know what’s happening. I’m not afraid of gaining weight.’ "

Marked by a restriction of calorie intake leading to low body weight, patients with anorexia nervosa also have a disturbance in experience of body weight or shape or undue influence of body weight or shape on self-evaluation. "Patients will focus on certain body parts, like how wide their thighs are, or they will walk in a peculiar way so their thighs won’t touch," explained Dr. Halmi, who founded the eating disorders program at the New York–Presbyterian Hospital/Westchester division. "When they look in the mirror they will focus on their abdomen and become very concerned that they’re too wide. But if you take a photograph of them and show them the photograph, they will acknowledge that they are thin."

The two subgroups of patients with anorexia nervosa include those who lose weight only by restricting what they eat (no binge eating or purging in the past 3 months) and those who lose weight by binge eating/purging (binge eating, self-induced vomiting, or misuse of laxatives or enemas in the past 3 months). The new aspect of diagnosing this in the DSM-5 includes qualifiers for partial remission or full remission. "Partial remission is defined as weight recovery but continued fear/preoccupation with body weight and shape," she said. "Full remission is defined as no criteria for anorexia nervosa met for a sustained period of time."

The severity of anorexia nervosa is measured by body mass index, ranging from mild (body mass index, 17 kg/m² or greater) to moderate (16-16.99 kg/m²), severe (BM, 15-15.99 kg/m²), or extreme (BMI less than 15 kg/m²). The level of severity may be increased for clinical symptoms, functional disability, and the need for supervision. "This is a serious, chronic illness," Dr. Halmi said. "You have to treat these patients sometimes for 2-3 years before they recover."

The psychological characteristics of the illness include a perfectionist need to control, inflexible thinking, obsessive-compulsive features and social withdrawal, and feelings of ineffectiveness. "These patients are not great adventurers," she noted. "They can be bright and accomplishing a lot in school, but inside, they are very afraid of confronting the world and are very insecure." Other characteristics include limited social spontaneity, restrained emotional expression, dependency, maturity fears, depression, and sexual disinterest.

Physical signs can include hypotension, hypothermia, and bradycardia. Those who binge eat and then vomit often present with tooth erosion, poor gum hygiene, swollen parotid glands "so they look like a chipmunk," and abrasions and scars on the dorsum of hands. Other serious long-term consequences of the illness include osteopenia and osteoporosis. "Once a child loses calcium in bones during their development, that can never be replaced; it puts them at risk for fractures in later life," Dr. Halmi said. "What you can do through nutritional rehabilitation is to prevent further mineral loss from the bones."

Certain serum chemistry tests can help you confirm a diagnosis of anorexia nervosa. Leukopenia with relative lymphocytosis is common. "You also want to measure their serum amylase, because if they’re vomiting, most of the time their serum amylase levels will be elevated," she said. In addition, mild metabolic acidosis is suggestive of laxative abuse. Elevated hepatic enzyme levels and hypercholesterolemia may be present, and elevated blood urea nitrogen levels indicate dehydration.

Dr. Halmi underscored the importance of checking for abuse of stimulants, including amphetamines, caffeine, and nicotine, for weight control. Patients who binge and purge "have a high incidence of drug abuse with alcohol or cocaine," she added. "Ipecac may be used to induce vomiting. That can be especially harmful, because ipecac can cause myocardial damage that is irreversible."

According to Dr. Halmi, the mortality for patients with anorexia nervosa is estimated to be about 7% at 10 years. At 30 years the mortality jumps to 18%-21%. The crude mortality is about 5% per decade. "In the long term, 50% of patients will recover, but about 25% will die of their illness, and about 25% will remain chronically ill for a long period of time," she said.

Few randomized, controlled trials of treatment for the illness exist, principally because it’s difficult to enroll an adequate sample size into such studies. "Also, anorexia nervosa patients are resistant to treatment, so to get them to enter a treatment trial is a real effort," she said. "In addition, medical complications can require withdrawal from treatment protocols."

Dr. Halmi described ideal treatment of patients with the illness as multifocused with compatible team personnel. Medical management is necessary, along with nutritional rehabilitation, psychotherapy, and family therapy, which is essential for adolescents, she said. "I emphasize this because once patients reach age 18, they are legal citizens, and you cannot force them to receive treatment unless they are near death. They have to be very ill before you can convince a judge they need to be committed. The longer they stay in their behavior of losing weight in their malnutrition state, the less likely they are to recover. People who are chronically underweight for longer than 6 years do not recover from this illness. Therefore, it’s important to diagnose this disorder and get them into treatment with an experienced team."

Limited positive evidence exists for cognitive-behavioral therapy for adults and family-based therapy for adolescents. Behavioral family therapy has been shown to be effective in five randomized trials. "Parents with high expressed emotion or criticism will do better with their anorectic adolescents in separated rather than whole family therapy," Dr. Halmi said. "In the short term, 10 sessions over 6 months is effective for intact families and patients low in obsessive-compulsive features."

Although about 20 randomized controlled studies of pharmacologic treatment have been performed to date, no "grade A" evidence exists for using medication in patients with anorexia nervosa. Category B evidence supports the use of 100 mg zinc gluconate or 14 mg elemental zinc per day for 2 months or olanzapine 5-15 mg/day. "The main problem in using olanzapine is compliance," Dr. Halmi said.

Negative evidence exists for prescribing antidepressants for patients with this illness, and insufficient evidence exists for using cyproheptadine up to 24 mg/day, but Dr. Halmi said she has found that some patients benefit from cyproheptadine. "It mainly acts not by increasing appetite, but by slightly reducing body movements," she said.

Dr. Halmi said she had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

LAS VEGAS – Patients with anorexia nervosa rank among the most difficult to manage because of their resistance to treatment, according to Dr. Katherine A. Halmi.

"Patients with this disorder characteristically do not wish to be treated; they are terrified to give up their illness," Dr. Halmi, professor emerita of psychiatry at Weill Cornell Medical College, New York, said at the annual psychopharmacology update held by the Nevada Psychiatric Association. "They know the diagnostic criteria better than most clinicians do. If you ask them, are you afraid of gaining weight? Many of them will say, ‘No, I don’t know what’s happening. I’m not afraid of gaining weight.’ "

Marked by a restriction of calorie intake leading to low body weight, patients with anorexia nervosa also have a disturbance in experience of body weight or shape or undue influence of body weight or shape on self-evaluation. "Patients will focus on certain body parts, like how wide their thighs are, or they will walk in a peculiar way so their thighs won’t touch," explained Dr. Halmi, who founded the eating disorders program at the New York–Presbyterian Hospital/Westchester division. "When they look in the mirror they will focus on their abdomen and become very concerned that they’re too wide. But if you take a photograph of them and show them the photograph, they will acknowledge that they are thin."

The two subgroups of patients with anorexia nervosa include those who lose weight only by restricting what they eat (no binge eating or purging in the past 3 months) and those who lose weight by binge eating/purging (binge eating, self-induced vomiting, or misuse of laxatives or enemas in the past 3 months). The new aspect of diagnosing this in the DSM-5 includes qualifiers for partial remission or full remission. "Partial remission is defined as weight recovery but continued fear/preoccupation with body weight and shape," she said. "Full remission is defined as no criteria for anorexia nervosa met for a sustained period of time."

The severity of anorexia nervosa is measured by body mass index, ranging from mild (body mass index, 17 kg/m² or greater) to moderate (16-16.99 kg/m²), severe (BM, 15-15.99 kg/m²), or extreme (BMI less than 15 kg/m²). The level of severity may be increased for clinical symptoms, functional disability, and the need for supervision. "This is a serious, chronic illness," Dr. Halmi said. "You have to treat these patients sometimes for 2-3 years before they recover."

The psychological characteristics of the illness include a perfectionist need to control, inflexible thinking, obsessive-compulsive features and social withdrawal, and feelings of ineffectiveness. "These patients are not great adventurers," she noted. "They can be bright and accomplishing a lot in school, but inside, they are very afraid of confronting the world and are very insecure." Other characteristics include limited social spontaneity, restrained emotional expression, dependency, maturity fears, depression, and sexual disinterest.

Physical signs can include hypotension, hypothermia, and bradycardia. Those who binge eat and then vomit often present with tooth erosion, poor gum hygiene, swollen parotid glands "so they look like a chipmunk," and abrasions and scars on the dorsum of hands. Other serious long-term consequences of the illness include osteopenia and osteoporosis. "Once a child loses calcium in bones during their development, that can never be replaced; it puts them at risk for fractures in later life," Dr. Halmi said. "What you can do through nutritional rehabilitation is to prevent further mineral loss from the bones."

Certain serum chemistry tests can help you confirm a diagnosis of anorexia nervosa. Leukopenia with relative lymphocytosis is common. "You also want to measure their serum amylase, because if they’re vomiting, most of the time their serum amylase levels will be elevated," she said. In addition, mild metabolic acidosis is suggestive of laxative abuse. Elevated hepatic enzyme levels and hypercholesterolemia may be present, and elevated blood urea nitrogen levels indicate dehydration.

Dr. Halmi underscored the importance of checking for abuse of stimulants, including amphetamines, caffeine, and nicotine, for weight control. Patients who binge and purge "have a high incidence of drug abuse with alcohol or cocaine," she added. "Ipecac may be used to induce vomiting. That can be especially harmful, because ipecac can cause myocardial damage that is irreversible."

According to Dr. Halmi, the mortality for patients with anorexia nervosa is estimated to be about 7% at 10 years. At 30 years the mortality jumps to 18%-21%. The crude mortality is about 5% per decade. "In the long term, 50% of patients will recover, but about 25% will die of their illness, and about 25% will remain chronically ill for a long period of time," she said.

Few randomized, controlled trials of treatment for the illness exist, principally because it’s difficult to enroll an adequate sample size into such studies. "Also, anorexia nervosa patients are resistant to treatment, so to get them to enter a treatment trial is a real effort," she said. "In addition, medical complications can require withdrawal from treatment protocols."

Dr. Halmi described ideal treatment of patients with the illness as multifocused with compatible team personnel. Medical management is necessary, along with nutritional rehabilitation, psychotherapy, and family therapy, which is essential for adolescents, she said. "I emphasize this because once patients reach age 18, they are legal citizens, and you cannot force them to receive treatment unless they are near death. They have to be very ill before you can convince a judge they need to be committed. The longer they stay in their behavior of losing weight in their malnutrition state, the less likely they are to recover. People who are chronically underweight for longer than 6 years do not recover from this illness. Therefore, it’s important to diagnose this disorder and get them into treatment with an experienced team."

Limited positive evidence exists for cognitive-behavioral therapy for adults and family-based therapy for adolescents. Behavioral family therapy has been shown to be effective in five randomized trials. "Parents with high expressed emotion or criticism will do better with their anorectic adolescents in separated rather than whole family therapy," Dr. Halmi said. "In the short term, 10 sessions over 6 months is effective for intact families and patients low in obsessive-compulsive features."

Although about 20 randomized controlled studies of pharmacologic treatment have been performed to date, no "grade A" evidence exists for using medication in patients with anorexia nervosa. Category B evidence supports the use of 100 mg zinc gluconate or 14 mg elemental zinc per day for 2 months or olanzapine 5-15 mg/day. "The main problem in using olanzapine is compliance," Dr. Halmi said.

Negative evidence exists for prescribing antidepressants for patients with this illness, and insufficient evidence exists for using cyproheptadine up to 24 mg/day, but Dr. Halmi said she has found that some patients benefit from cyproheptadine. "It mainly acts not by increasing appetite, but by slightly reducing body movements," she said.

Dr. Halmi said she had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com

LAS VEGAS – Patients with anorexia nervosa rank among the most difficult to manage because of their resistance to treatment, according to Dr. Katherine A. Halmi.

"Patients with this disorder characteristically do not wish to be treated; they are terrified to give up their illness," Dr. Halmi, professor emerita of psychiatry at Weill Cornell Medical College, New York, said at the annual psychopharmacology update held by the Nevada Psychiatric Association. "They know the diagnostic criteria better than most clinicians do. If you ask them, are you afraid of gaining weight? Many of them will say, ‘No, I don’t know what’s happening. I’m not afraid of gaining weight.’ "

Marked by a restriction of calorie intake leading to low body weight, patients with anorexia nervosa also have a disturbance in experience of body weight or shape or undue influence of body weight or shape on self-evaluation. "Patients will focus on certain body parts, like how wide their thighs are, or they will walk in a peculiar way so their thighs won’t touch," explained Dr. Halmi, who founded the eating disorders program at the New York–Presbyterian Hospital/Westchester division. "When they look in the mirror they will focus on their abdomen and become very concerned that they’re too wide. But if you take a photograph of them and show them the photograph, they will acknowledge that they are thin."

The two subgroups of patients with anorexia nervosa include those who lose weight only by restricting what they eat (no binge eating or purging in the past 3 months) and those who lose weight by binge eating/purging (binge eating, self-induced vomiting, or misuse of laxatives or enemas in the past 3 months). The new aspect of diagnosing this in the DSM-5 includes qualifiers for partial remission or full remission. "Partial remission is defined as weight recovery but continued fear/preoccupation with body weight and shape," she said. "Full remission is defined as no criteria for anorexia nervosa met for a sustained period of time."

The severity of anorexia nervosa is measured by body mass index, ranging from mild (body mass index, 17 kg/m² or greater) to moderate (16-16.99 kg/m²), severe (BM, 15-15.99 kg/m²), or extreme (BMI less than 15 kg/m²). The level of severity may be increased for clinical symptoms, functional disability, and the need for supervision. "This is a serious, chronic illness," Dr. Halmi said. "You have to treat these patients sometimes for 2-3 years before they recover."

The psychological characteristics of the illness include a perfectionist need to control, inflexible thinking, obsessive-compulsive features and social withdrawal, and feelings of ineffectiveness. "These patients are not great adventurers," she noted. "They can be bright and accomplishing a lot in school, but inside, they are very afraid of confronting the world and are very insecure." Other characteristics include limited social spontaneity, restrained emotional expression, dependency, maturity fears, depression, and sexual disinterest.

Physical signs can include hypotension, hypothermia, and bradycardia. Those who binge eat and then vomit often present with tooth erosion, poor gum hygiene, swollen parotid glands "so they look like a chipmunk," and abrasions and scars on the dorsum of hands. Other serious long-term consequences of the illness include osteopenia and osteoporosis. "Once a child loses calcium in bones during their development, that can never be replaced; it puts them at risk for fractures in later life," Dr. Halmi said. "What you can do through nutritional rehabilitation is to prevent further mineral loss from the bones."

Certain serum chemistry tests can help you confirm a diagnosis of anorexia nervosa. Leukopenia with relative lymphocytosis is common. "You also want to measure their serum amylase, because if they’re vomiting, most of the time their serum amylase levels will be elevated," she said. In addition, mild metabolic acidosis is suggestive of laxative abuse. Elevated hepatic enzyme levels and hypercholesterolemia may be present, and elevated blood urea nitrogen levels indicate dehydration.

Dr. Halmi underscored the importance of checking for abuse of stimulants, including amphetamines, caffeine, and nicotine, for weight control. Patients who binge and purge "have a high incidence of drug abuse with alcohol or cocaine," she added. "Ipecac may be used to induce vomiting. That can be especially harmful, because ipecac can cause myocardial damage that is irreversible."

According to Dr. Halmi, the mortality for patients with anorexia nervosa is estimated to be about 7% at 10 years. At 30 years the mortality jumps to 18%-21%. The crude mortality is about 5% per decade. "In the long term, 50% of patients will recover, but about 25% will die of their illness, and about 25% will remain chronically ill for a long period of time," she said.

Few randomized, controlled trials of treatment for the illness exist, principally because it’s difficult to enroll an adequate sample size into such studies. "Also, anorexia nervosa patients are resistant to treatment, so to get them to enter a treatment trial is a real effort," she said. "In addition, medical complications can require withdrawal from treatment protocols."

Dr. Halmi described ideal treatment of patients with the illness as multifocused with compatible team personnel. Medical management is necessary, along with nutritional rehabilitation, psychotherapy, and family therapy, which is essential for adolescents, she said. "I emphasize this because once patients reach age 18, they are legal citizens, and you cannot force them to receive treatment unless they are near death. They have to be very ill before you can convince a judge they need to be committed. The longer they stay in their behavior of losing weight in their malnutrition state, the less likely they are to recover. People who are chronically underweight for longer than 6 years do not recover from this illness. Therefore, it’s important to diagnose this disorder and get them into treatment with an experienced team."

Limited positive evidence exists for cognitive-behavioral therapy for adults and family-based therapy for adolescents. Behavioral family therapy has been shown to be effective in five randomized trials. "Parents with high expressed emotion or criticism will do better with their anorectic adolescents in separated rather than whole family therapy," Dr. Halmi said. "In the short term, 10 sessions over 6 months is effective for intact families and patients low in obsessive-compulsive features."

Although about 20 randomized controlled studies of pharmacologic treatment have been performed to date, no "grade A" evidence exists for using medication in patients with anorexia nervosa. Category B evidence supports the use of 100 mg zinc gluconate or 14 mg elemental zinc per day for 2 months or olanzapine 5-15 mg/day. "The main problem in using olanzapine is compliance," Dr. Halmi said.

Negative evidence exists for prescribing antidepressants for patients with this illness, and insufficient evidence exists for using cyproheptadine up to 24 mg/day, but Dr. Halmi said she has found that some patients benefit from cyproheptadine. "It mainly acts not by increasing appetite, but by slightly reducing body movements," she said.

Dr. Halmi said she had no relevant financial conflicts to disclose.

dbrunk@frontlinemedcom.com