Medical Management and Prognosis of Eating Disorders

Treatment of anorexia consists of medical management, psychotherapy, and nutrition counseling. The goals of treatment are to normalize body weight, correct the preoccupation with weight loss, and prevent relapse. Monitoring weight, vital signs and serum electrolytes is essential. Weight gain should not be excessive. Rapid refeeding can lead to excessive bloating, edema, and in rare instances, congestive heart failure.44

In some cases of anorexia, antidepressants may be indicated, although studies have demonstrated little benefit in using antidepressants during the weight-gain phase of treatment.21,45 However, tricyclic antidepressants are contraindicated individuals who present with prolongation of the QT interval on an ECG. This finding, coupled with tricyclics, can increase the risk of ventricular tachycardia and death.8

For those individuals presenting with osteopenia, dietary calcium 1000 to 1500 mg/d), vitamin D (400 IU), and routine bone density examinations are recommended.1,21 The benefits of estrogen replacement for this condition in individuals with anorexia have not been established.

Family therapy is often used to address the psychological health of individuals with anorexia. Psychodynamic psychotherapy, in combination with behavioral strategies, is helpful in addressing issues of body image, weight management, and predisposing and precipitating factors associated with anorexia.12,46,47

Nutrition is a vital component of treatment for individuals with anorexia. A registered dietician should be an integral part of the treatment team and will provide education on nutrition, adjustment caloric and nutritional intake, limitations on exercise, and will monitor the diet to avoid the refeeding syndrome.

Limiting physical exercise is recommended as part of the treatment for anorexia, which limits energy expended and contributes to a balanced weight. Limiting physical activity is also used as a motivational strategy to help maintain healthy eating habits so the individual with anorexia can return to favorite sports or exercise routines.

Although most treatment for anorexia can occur in outpatient settings, those who are at risk medically and/or psychiatrically, require inpatient care. Indications for inpatient treatment include low or rapid weight loss, severe electrolyte imbalance, temperature less than 36ºC, pulse less than 45 BPM, altered mental status or other signs of severe malnutrition, cardiac disturbances, psychosis, or high suicidal risk.12

The prognosis for individuals with anorexia remains guarded and depends on a variety of prognostic factors such as age of onset, weight loss at diagnosis, duration of symptoms, duration of inpatient care, and state of family relationships. Onset of anorexia before adulthood carries a more favorable outcome. However, when onset occurs at an age younger than 11 years the prognosis is poor. Ashort duration of involvement of the organ systems, short inpatient treatment period, and a good relationship between the parents and child tends toward a more favorable outcome.

The mortality rate in anorexia is 10 to 20%. In general, 50% of individuals with anorexia recover completely, while 20% remain emaciated, 25% are thin, or 5 to10%, die of starvation.12,21,48

Treatment of bulimia includes nutrition counseling, medications, and psychotherapy. Nutrition counseling is used to guide individuals toward normal eating patterns and healthy food choices. Reintroducing“feared” foods in small amounts is used to teach those with bulimia to enjoy these foods without needing to overeat.

The most commonly prescribed medications for individuals with bulimia are antidepressants, such as Prozac and Norpramin. These medications help relieve depressive symptoms associated with bulimia nervosa and help individuals achieve a more healthy body image. In some cases, antiemetics, such as Zofran, are prescribed on a shortterm basis at the onset of treatment to help reduce the stimuli to vomit.

Counseling, particularly cognitive behavioral therapy (CBT), is used to encourage rational attitudes about weight, moderation of high self-expectations, enhancement of self-esteem, and alleviation of stress. CBT helps people with bulimia to systematically challenge their assumptions linking weight to selfesteem, while the individual with bulimia is encouraged to set the treatment goals, family involvement in treatment also is encouraged.

The prognosis for individuals with bulimia also remains guarded. A 10-year follow-up study found that 52% of people with bulimia had recovered fully and 9% continued to experience symptoms of bulimia.49 A study of 222 individuals treated with antidepressants and intensive group therapy found that after 11.5 years, 70% were in full or partial remission, but 11% still met the criteria for bulimia.50 Although cognitive-behavior therapy and medication have shown to benefit
those with bulimia, they fail in approximately one-third to one-half of cases. Relapse rates are around 30%.21,32 A good prognosis has been associated with shorter duration of illness, younger age of onset, and higher social class.40 Poor prognosis has been associated with a history of substance abuse, premorbid and paternal obesity, and personality disorder.50-55

Current treatment for binge eating disorder includes cognitivebehavioral therapy, interpersonal psychotherapy, drug therapy, and a supervised weight loss program. Cognitive behavioral therapy involves keeping track of eating habits and methods for changing unhealthy eating behaviors. Interpersonal psychotherapy focuses on relationships with friends, family, and eating. Antidepressants are helpful in treating depression and other mood disorders that may be associated with binge eating. Fluoxetine has been found to be effective in decreasing the frequency of bingeing episodes. Greeno and Wing noted a decrease in caloric intake of more than 60 kcal/d in the treatment group receiving fluoxetine when compared with the placebo group. The authors suggested that the effect of this medication is to induce satiety rather than to decrease appetite, as there was no decrease in the frequency of eating noted.56 Finally, the NIDDK recommends that individuals with binge eating disorder seek a supervised weight loss program that also offers treatment for eating disorders as the best approach for successful weight loss.35

The prognosis for binge eating is circumspect. Supervised weight loss with psychotherapy may offer the best results. For more information concerning this eating disorder, the reader can contact the Weight-control Information Network at win@info.niddk.nih.gov.

Treatment of pica is focused on education, behavior changes, diet, and medical intervention for specific problems such as anemia, gastrointestinal obstruction, or infection. Diet analysis, assessment of nutritional beliefs, and nutrition counseling also are appropriate interventions. Psychological counseling or behavior therapy can be useful adjuncts, especially for individuals with OCD and children with developmental disabilities. Behavioral strategies that have been effective are antecedent manipulation; discrimination training between edible and inedible items; contingent aversive oral taste (lemon), smell sensation (ammonia) and physical sensation (water mist); overcorrection (correct the environment or practice appropriate alternative response); and reinforcement.57 Parents of children with pica should be instructed to provide closer supervision of children during play and to child-proof their home and play environments. The removal of toxic substances from the environment, particularly lead-based paint, is important.

Not all forms of pica are dangerous and cause medical complications. Pica frequently remits spontaneously in young children and pregnant women. However, it may persist for years in individuals with mental retardation and developmental disabilities. Long-term follow-up with psychological and nutrition counselors may be warranted in such cases.