Best Dx/Best Rx: Anorexia Nervosa/Bulimia Nervosa and Binge Eating
Anorexia Nervosa
Bulimia Nervosa and Binge Eating
Anorexia Nervosa
W. Stewart Agras, MD
Stanford University School of Medicine
Definition/Key Clinical Features
Differential Diagnosis
Best Tests
Best Therapy
Best References
Definition/Key Clinical Features
- A chronic disorder of severe dietary restriction occurring predominantly in women
- Frequent psychiatric comorbidity, leading to chronic starvation
- Symptoms
- Severe dietary restriction
- Marked weight loss
- Amenorrhea in females
- Depression
- Features
- Distortion of body-image perception
- Excessive exercise
- Obsessive thinking and behavior regarding food
- Intense fear of gaining weight
Differential Diagnosis
- Hypopituitarism
- Schizophrenia
Best Tests
- Physical examination
- Marked emaciation
- ≥ 15% reduction in ideal body weight
- Dry skin that may be covered with lanugo
- Cold, cyanotic extremities sometimes accompanied by the following:
- Peripheral edema
- Bradycardia
- Hypotension
- Psychological examination
- Depressive symptoms
- Anxiety disorders
- Cognitive impairment
- Poor concentration
- Poor memory
- Poor judgment
- Laboratory findings
- Anemia
- Leukopenia
- Elevated cholesterol and β-carotene
- Osteoporosis
- Abnormal hormonal findings caused by starvation
- Significantly decreased plasma gonadotropin levels
- 24 hr luteinizing hormone pattern resembles that of prepubertal girl
- Low follicle-stimulating hormone and estrogen
- Elevated growth hormone
- Low total serum thyroxine
- Low triiodothyronine
- Elevated resting plasma cortisol
- Decreased metabolic clearance of cortisol
Best Therapy*
- Patient weighs 75–90% of ideal body weight
- If weight loss is caused by self-starvation, refer for psychotherapy
- Patient weighs < 70–75% of ideal body weight
- Hospitalize for medical stabilization, weight restoration
- If weight loss is caused by self-starvation
- Restore weight to at least 90% of ideal body weight
- Refer for psychotherapy
- Follow up
Psychological Therapy
- Positive reinforcement for small and continued weight gains
- Cognitive-behavioral therapy, including family, after some weight has been gained
- Family therapy for younger patients
Pharmacologic Therapy
- Selective serotonin reuptake inhibitors for patients with obsessive-compulsive disorder
Best References
Dare, et al. Br J Psychiatry 2001;178:216. [PMID 11230031]
Kaye, et al. Biol Psychiatry 2001;49:644. [PMID 11297722]
Strober, et al. Am J Psychiatry 2000;157:393. [PMID 10698815]
* To obtain additional drug information, click on the DrugInfo tab in the left column, or click on the following link: http://search.medscape.com/drug-reference-search?queryText=
December 2011
Bulimia Nervosa and Binge Eating Disorder
W. Stewart Agras, MD
Stanford University School of Medicine
Definition/Key Clinical Features
Differential Diagnosis
Best Tests
Best Therapy
Best References
Definition/Key
Clinical Features
- Chronic conditions accompanied by an increased risk of psychiatric illness
- Female predominance
- Bulimia nervosa
- Binge eating followed by purging or other compensatory behavior
- Self-induced vomiting
- Laxative abuse
- Excessive exercise
- Fasting
- Symptoms
- Fatigue
- Decreased energy
- Abdominal pain
- Amenorrhea in females
- Depression
- Weight and shape concerns less extreme than in anorexia nervosa
- Past episode of anorexia nervosa in one quarter of patients
- May be associated with type 1 diabetes mellitus in adolescents
- Binge-eating disorder
- Episodic, without compensatory purging
- Periods of dietary restriction alternating with binges
- Overweight or obesity common
Differential Diagnosis
- Bulimia
- Causes of spontaneous vomiting
- Binge eating
Best Tests
Bulimia Nervosa
- Diagnostic criteria
- Binge eating and purging on average ≥ 2 times/wk for 3 mo
- Physical examination
- Dry skin
- Evidence of dehydration
- Fluctuant salivary gland hypertrophy
- Tooth decay, periodontal disease
- Psychological examination
- Major depression (positive history in > 50%)
- Anxiety disorders
- Alcohol or drug dependency or abuse
- Laboratory tests
- Elevated serum amylase
- Metabolic alkalosis
- Elevated serum bicarbonate
- Hypochloremia
- Hypokalemia
- Binge Eating
- Diagnostic criteria
- Binge eating ≥ 2 days/wk for 6 mo
- History and physical examination
- Overweight or obese
- Sizable weight gain or marked weight cycling
- Major depression
- Anxiety disorders
- Personality disorders
Best Therapy*
Psychotherapy
- Binge eating and/or purging twice a week or more
- Outpatient cognitive-behavioral therapy (CBT) ± antidepressants
- Binge eating and/or purging once a week
- Self-help manual
- If treatment fails, institute outpatient CBT
Pharmacologic Therapy
- Antidepressants
- Tricyclic antidepressants (e.g., desipramine, 150–300 mg/day)
- Selective serotonin reuptake inhibitors (e.g., fluoxetine, 60 mg/day)
- Topiramate
Best References
American Psychiatric Association. Am J Psychiatry 2000;157(1 Suppl):1. [PMID 10698815]
Hay PJ, et al. Cochrane Database Syst Rev 2004;(3):CD000562.
Hoopes SP, et al. J Clin Psychiatry 2003;64:1335. [PMID 14658948]
McElroy SL, et al. J Clin Psychiatry 2004;65:1463. [PMID 15554757]
Strober M, et al. Am J Psychiatry 2000;157:393. [PMID 10698815]
* To obtain additional drug information, click on the DrugInfo tab in the left column, or click on the following link: http://search.medscape.com/drug-reference-search?queryText=
December 2011
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