Anorexia Nervosa

Bulimia Nervosa and Binge Eating

Anorexia Nervosa

W. Stewart Agras, M.D.
Stanford University School of Medicine

Definition/Key Clinical Features
Differential Diagnosis
Best Tests
Best Therapy
Best References

Definition

• A chronic disorder of severe dietary restriction occurring predominantly in women
• Frequent psychiatric comorbidity, leading to chronic starvation

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Key Clinical Features

• Symptoms
  • Severe dietary restriction
  • Marked weight loss
  • Amenorrhea
  • Depression
• Features
  • Distortion of body-image perception
  • Excessive exercise
  • Obsessive thinking and behavior regarding food
  • Intense fear of gaining weight
    

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Differential Diagnosis

• Hypopituitarism
• Schizophrenia

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Best Tests

• Physical exam
  • 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 exam
  • Depressive symptoms
  • Anxiety disorders
  • Cognitive impairment
    • Poor concentration
    • Poor memory
    • Poor judgment
• Lab 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 FSH and estrogen
    • Elevated growth hormone
    • Low total serum thyroxine
    • Low triiodothyronine
    • Elevated resting plasma cortisol
    • Decreased metabolic clearance of cortisol

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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

• SSRIs for patients with obsessive-compulsive disorder

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Best References

Dare, et al: Br J Psychiatry 178:216, 2001

Kaye, et al: Biol Psychiatry 49:644, 2001

Strober, et al: Am J Psychiatry 157:393, 2000

July 2004

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Bulimia Nervosa and Binge Eating

W. Stewart Agras, M.D.
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
• 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
• Episodic, without compensatory purging
• Periods of dietary restriction alternating with binges
• Overweight or obesity common

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Differential Diagnosis

• Bulimia
• Causes of spontaneous vomiting
• Binge eating
• Brain injury (rare)

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Best Tests

• 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 (uncommon)

• 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

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Best Therapy

• Binge eating and/or purging twice a week or more
• Outpatient cognitive-behavioral therapy (CBT) ± antidepressants
• Binge eating and/or purging once a wk
• Self-help manual
• If treatment fails, institute outpatient CBT

• Antidepressants
• Tricyclic antidepressants (e.g., desipramine, 150–300 mg/day)
• Selective serotonin reuptake inhibitors (e.g., fluoxetine, 60 mg/day)
• Topiramate
• Dose: Up to 600 mg/day
• Cost/mo: $522.75

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Best References

American Psychiatric Association: Am J Psychiatry 157(1 suppl):1, 2000 [PMID 10642782]

Hay PJ, et al: Cochrane Database Syst Rev (3):CD000562, 2004 [PMID 15266434]

Hoopes SP, et al: J Clin Psychiatry 64:1335, 2003 [PMID 14658948]

McElroy SL, et al: J Clin Psychiatry 65:1463, 2004 [PMID 15554757]

Strober M, et al: Am J Psychiatry 157:393, 2000 [PMID 10698815]

September 2006