Eating DisordersEating Disorders Anorexia NervosaAnorexia Nervosa

Bulimia NervosaBulimia Nervosa Eating Disorder NOSEating Disorder NOS

Nichole Grier MDNichole Grier MDUNC Dept. of PsychiatryUNC Dept. of Psychiatry

What is “normal” eating?What is “normal” eating? How do you know if you are “fat” or How do you know if you are “fat” or

“too thin”?“too thin”? When is it a “mental illness”?When is it a “mental illness”? Does anyone talk about it?Does anyone talk about it? How common is it?How common is it? Whose fault is it?Whose fault is it? Who recovers?Who recovers? How?How?

What is Healthy Eating?What is Healthy Eating?

•Mindful: Know the difference between physical and emotional cues and needs. Eat when you are hungry; stop when you are full. Meet your body’s needs.

•Enjoyable: Eat pleasurable foods without guilt or anxiety.

•Flexible: Be able to eat needed amount in available time. No calorie counting. Eat a variety of foods. Don’t avoid any food group. Try new things without knowing all ingredients.

Defining “Healthy” WeightDefining “Healthy” Weight PediatricsPediatrics

Standard: 50Standard: 50thth Percentile BMI-for-age, CDC Percentile BMI-for-age, CDC growth charts for USgrowth charts for US

Utilize height and weight history to plot growth on Utilize height and weight history to plot growth on BMI-for-age chart to establish individualized goalBMI-for-age chart to establish individualized goal

AdultsAdults Standard: Medium frame, 1983 Metropolitan Standard: Medium frame, 1983 Metropolitan

Height/Weight Tables, or BMIHeight/Weight Tables, or BMI Set minimum goal for BMI 19.5Set minimum goal for BMI 19.5 Individualize based on premorbid weight, Individualize based on premorbid weight,

resumption of menses, physical health indicatorsresumption of menses, physical health indicators

What about fat . . .What about fat . . .

The American College of Sports Medicine The American College of Sports Medicine (ACSM) recommends that males age 16 and (ACSM) recommends that males age 16 and under with < 7% body fat and males over 16 under with < 7% body fat and males over 16 years of age with < 5% body fat not be allowed years of age with < 5% body fat not be allowed to compete unless they have medical clearance. to compete unless they have medical clearance.

The ACSM recommends 12%-14% body fat as The ACSM recommends 12%-14% body fat as

the minimum safe percent body fat for high the minimum safe percent body fat for high school girls. school girls.

some historical context . . .some historical context . . .

““Anorexia Nervosa” was first described Anorexia Nervosa” was first described as a distinct diagnostic entity in 1873as a distinct diagnostic entity in 1873

““Bulimia Nervosa” became a diagnostic Bulimia Nervosa” became a diagnostic category in 1979 category in 1979

Keyes studyKeyes study

Healthy malesHealthy males Voluntary starvation then refeedingVoluntary starvation then refeeding Development of apathy, ritualistic Development of apathy, ritualistic

behaviors, preoccupation with foodbehaviors, preoccupation with food Physical symptoms cold intolerance, Physical symptoms cold intolerance,

edema, slowed heart rate, diminished edema, slowed heart rate, diminished sexual interestsexual interest

Increased caloric needs with refeedingIncreased caloric needs with refeeding Onset binge urgesOnset binge urges

DSM-IV criteria:DSM-IV criteria:

Anorexia NervosaAnorexia Nervosa RefusalRefusal to maintain body weight at or above that to maintain body weight at or above that

expected for age & height (<85%)expected for age & height (<85%) Intense Intense fearfear of gaining weight or becoming fat of gaining weight or becoming fat DisturbanceDisturbance in the way one’s body size is in the way one’s body size is

experienced, OR undue influence of body size on experienced, OR undue influence of body size on self evaluation, OR denial of seriousness of low self evaluation, OR denial of seriousness of low weight.weight.

Amenorrhea in postmenarcheal females (absence Amenorrhea in postmenarcheal females (absence of 3 or more consecutive menstrual cycles)of 3 or more consecutive menstrual cycles)

Anorexia Nervosa: SubtypesAnorexia Nervosa: Subtypes

Restricting TypeRestricting Type: : during current episode during current episode of AN, no regular binge eating or purging of AN, no regular binge eating or purging behaviorbehavior

Binge-Eating/Purging TypeBinge-Eating/Purging Type: : during during current episode of AN, regular binge current episode of AN, regular binge eating or purgingeating or purging

Anorexia nervosa is not a Anorexia nervosa is not a disorder of appetite.disorder of appetite.

May report decreased appetiteMay report decreased appetite

Others FEAR appetiteOthers FEAR appetite

DSM-IV criteria:DSM-IV criteria: Bulimia NervosaBulimia Nervosa

Recurrent episodes of binge eatingRecurrent episodes of binge eating objectively a large amount of foodobjectively a large amount of food individual feels “out of control”individual feels “out of control”

Recurrent compensatory mechanismsRecurrent compensatory mechanisms self-induced vomitingself-induced vomiting laxative uselaxative use FastingFasting excessive exerciseexcessive exercise

DSM IV criteria: DSM IV criteria:

Bulimia Nervosa Bulimia Nervosa

Binge/Purge episodes occur, on average, at Binge/Purge episodes occur, on average, at least two or more times a week for at least least two or more times a week for at least three monthsthree months

Self-esteem unduly influenced by Self-esteem unduly influenced by weight/body shapeweight/body shape

Current weight does not meet criteria for AN Current weight does not meet criteria for AN (>85% IBW)(>85% IBW)

Bulimia Nervosa: subtypesBulimia Nervosa: subtypes

Purging typePurging type: : self-induced self-induced vomiting, laxative abuse, diuretic vomiting, laxative abuse, diuretic abuseabuse

Non-purging typeNon-purging type: : restricting, restricting, over-exercisingover-exercising

Eating Disorder NOSEating Disorder NOS

Subsyndromal AN or BNSubsyndromal AN or BN Current nomenclature for set of Current nomenclature for set of

criteria under investigation as “Binge criteria under investigation as “Binge Eating Disorder”Eating Disorder”

DSM IV Research Criteria:DSM IV Research Criteria:Binge Eating DisorderBinge Eating Disorder

Recurrent episodes of binge eating:Recurrent episodes of binge eating: large amount with subjective loss of controllarge amount with subjective loss of control

Associated with 3 or more: Associated with 3 or more: eating rapidly, eating until uncomfortably full, eating rapidly, eating until uncomfortably full, eating in private (embarrassment), eating when not eating in private (embarrassment), eating when not physically hungry, feeling guilty about eatingphysically hungry, feeling guilty about eating

Marked distress regarding binge Marked distress regarding binge eatingeating

Binge eating occurs, on average, at Binge eating occurs, on average, at least twice/week for six monthsleast twice/week for six months

Binge Eating DisorderBinge Eating Disorder Usually associated with overweight or Usually associated with overweight or

obesityobesity Approximately 30% of individuals Approximately 30% of individuals

presenting to medical weight loss presenting to medical weight loss programs meet criteria for BEDprograms meet criteria for BED

Obesity itself is not a psychiatric illness, Obesity itself is not a psychiatric illness, but 8% of overweight women and almost but 8% of overweight women and almost one third of those presenting for weight one third of those presenting for weight loss treatment meet criteria for BEDloss treatment meet criteria for BED

Often hard to diagnose – different from Often hard to diagnose – different from emotional eating /grazingemotional eating /grazing

Eating Disorders: EpidemiologyEating Disorders: Epidemiology

Abnormal eating can be found in all Abnormal eating can be found in all cultures but eating disorders are far more cultures but eating disorders are far more common in industrialized countriescommon in industrialized countries

EDs occur in all ethnic and EDs occur in all ethnic and socioeconomic groups in the US, socioeconomic groups in the US, although they are far more prevalent in although they are far more prevalent in the caucasian community and seem to the caucasian community and seem to have lowest rates in African American have lowest rates in African American communitycommunity

Anorexia Nervosa: how Anorexia Nervosa: how common?common?

AN incidence around 8/100,000 per AN incidence around 8/100,000 per yearyear

AN average prevalence among AN average prevalence among young females around 0.3%young females around 0.3%

About one third of AN population About one third of AN population enters mental health careenters mental health care

Increasing incidence in past century Increasing incidence in past century until 1970’s, particularly in 15-24 until 1970’s, particularly in 15-24 year old age group; debate about year old age group; debate about increase or decrease in rates since increase or decrease in rates since thenthen

Bulimia Nervosa: how Bulimia Nervosa: how common?common?

BN incidence 11-13/100,000 per BN incidence 11-13/100,000 per year in 1980s then decreasing year in 1980s then decreasing through 1990s to around through 1990s to around 6.6/100,000 per year in 20006.6/100,000 per year in 2000

BN prevalence around 1% of young BN prevalence around 1% of young femalesfemales

BN population enters mental BN population enters mental health treatment at very low ratehealth treatment at very low rate

ED NOS: how common?ED NOS: how common?

60% of the eating disorder cases in 60% of the eating disorder cases in outpatient settingsoutpatient settings

Unknown incidence, changing Unknown incidence, changing definitiondefinition

BED prevalence in US 2-5% and BED prevalence in US 2-5% and possibly occurring more frequently possibly occurring more frequently in AA community than in caucasian in AA community than in caucasian communitycommunity

All ages at risk, but . . .All ages at risk, but . . .

Eating disorders have onset most Eating disorders have onset most commonly in teen and young adult commonly in teen and young adult years, but may occur at other ages (BN years, but may occur at other ages (BN slightly later peak onset than AN)slightly later peak onset than AN)

<10% have onset prior to puberty<10% have onset prior to puberty

Eating Disorders: MalesEating Disorders: Males

Up to 10% of AN & BN patients are maleUp to 10% of AN & BN patients are male As many as 25% of BED patients are maleAs many as 25% of BED patients are male Males with eating disorders are more likely Males with eating disorders are more likely

to have once been overweight and more to have once been overweight and more likely to have used exercise for weight likely to have used exercise for weight controlcontrol

Males may be less likely to pursue Males may be less likely to pursue treatment for an eating disorder, but treatment for an eating disorder, but eating disorders are just as dangerous for eating disorders are just as dangerous for males as they are for femalesmales as they are for females

SurveySurvey

Dieted in the past year: 62% of high Dieted in the past year: 62% of high school girls,school girls, 40% of high school boys 40% of high school boys

Ever binged and purged: 13% of Ever binged and purged: 13% of adolescent girls, 7% of adolescent boysadolescent girls, 7% of adolescent boys

At least one third of junior high school At least one third of junior high school girls admit concerns about weightgirls admit concerns about weight

6% of 106% of 10thth grade boys have used grade boys have used laxativeslaxatives

Higher rates in those with alcoholismHigher rates in those with alcoholism Higher rates when not involved in athletics Or when Higher rates when not involved in athletics Or when

competing at elite levelcompeting at elite level

OutcomesOutcomes

AN: mortality 5-6% per decade of follow-up; AN: mortality 5-6% per decade of follow-up; SMR 9.6 in studies with 6-12 years of follow-up, SMR 9.6 in studies with 6-12 years of follow-up, 3.7 when 20-40 years of follow-up3.7 when 20-40 years of follow-up

Causes of death: suicide, starvation, cardiac Causes of death: suicide, starvation, cardiac eventsevents

Risk factors for death: BMI<13, body weight Risk factors for death: BMI<13, body weight <60%, low serum albumin<60%, low serum albumin

Suicides do not occur exclusively during Suicides do not occur exclusively during significant underweightsignificant underweight

Purging behaviors are worse prognostic sign Purging behaviors are worse prognostic sign than restricting alonethan restricting alone

CourseCourse

AN: half will have full recovery; up to 20% with AN: half will have full recovery; up to 20% with chronic unremitting coursechronic unremitting course

BN: 80% recovery if treated within first 5 years BN: 80% recovery if treated within first 5 years of illness; recovery falls to 20% by 15 years of of illness; recovery falls to 20% by 15 years of illnessillness

Much crossover between AN and BNMuch crossover between AN and BN Positive indicators for recovery: early onset, Positive indicators for recovery: early onset,

early treatment, higher weight at discharge or early treatment, higher weight at discharge or step-down, good social support, good step-down, good social support, good premorbid psychological functioningpremorbid psychological functioning

Psychiatric comorbidityPsychiatric comorbidity

More than a quarter of ED patients have a More than a quarter of ED patients have a comorbid mood disordercomorbid mood disorder

Comorbid anxiety disorder in up to half of AN Comorbid anxiety disorder in up to half of AN patients, up to 75% of BN patientspatients, up to 75% of BN patients

Comorbid alcohol abuse, drug abuse, Comorbid alcohol abuse, drug abuse, impulsivity common impulsivity common

>90% have at least one additional psychiatric >90% have at least one additional psychiatric diagnosis in lifetime, 50% at least one diagnosis in lifetime, 50% at least one concurrent with episode of ANconcurrent with episode of AN

Morbidity: Mental healthMorbidity: Mental health

Poor sleep and Depressive symptoms Poor sleep and Depressive symptoms secondary to starvation itselfsecondary to starvation itself

Antidepressants generally ineffective at low Antidepressants generally ineffective at low weightsweights

Cognitive impairment during underweight, Cognitive impairment during underweight, changes in brain volumechanges in brain volume

Increased anxiety during weight gain Increased anxiety during weight gain secondary to changing hormonal milieu and secondary to changing hormonal milieu and increasing serotoninincreasing serotonin

Adverse effects of major illness episode on Adverse effects of major illness episode on normal developmental trajectorynormal developmental trajectory

Morbidity: ReproductionMorbidity: Reproduction

Reduced fertility at low weightReduced fertility at low weight Higher rates of obstetric difficultiesHigher rates of obstetric difficulties Decreased intrauterine growth of babyDecreased intrauterine growth of baby

Morbidity: Bone healthMorbidity: Bone health Decrease in peak bone mineral densityDecrease in peak bone mineral density Calcium supplements less effective at low Calcium supplements less effective at low

weightweight Weight-bearing exercise helpful but cannot Weight-bearing exercise helpful but cannot

offset adverse effects of underweightoffset adverse effects of underweight Estrogen supplements alone do not preserve Estrogen supplements alone do not preserve

bone density in underweight premenopausal bone density in underweight premenopausal femalesfemales

Bisphosphonates teratogenic potential Bisphosphonates teratogenic potential unknown unknown

Morbidity: Body image, Self esteemMorbidity: Body image, Self esteem

Initial weight gain truncal. Degree of Initial weight gain truncal. Degree of redistribution variableredistribution variable

Lower rates of marriage and Lower rates of marriage and childbearingchildbearing

Decreased achievement relative to Decreased achievement relative to potentialpotential

What causes an eating disorder?What causes an eating disorder?

Multifactorial Multifactorial Strong evidence of genetic Strong evidence of genetic

component from twin studiescomponent from twin studiesBUTBUT

Higher incidence in industrialized Higher incidence in industrialized countries AND not everyone with a countries AND not everyone with a weight concern develops an eating weight concern develops an eating disorderdisorder

Genetic factorsGenetic factors

58-88% of risk for developing AN, and roughly 58-88% of risk for developing AN, and roughly same for BNsame for BN

Eating and Body-related behavioral and Eating and Body-related behavioral and attitudinal factors appear to have heritable attitudinal factors appear to have heritable componentcomponent

BMI highly heritable and independent of ED-BMI highly heritable and independent of ED-related heritable factorsrelated heritable factors

AN and Chromosome 1AN and Chromosome 1 BN and self-induced vomiting and Chromosome BN and self-induced vomiting and Chromosome

1010

Other factorsOther factors

Developmental eventsDevelopmental events Family dynamicsFamily dynamics Peer milieuPeer milieu Cultural influencesCultural influences

““Genetics loads the gun . . .Genetics loads the gun . . .Environment pulls the trigger”Environment pulls the trigger”

(C. Bulik)(C. Bulik)

The assessmentThe assessment

Ask About:Ask About:

Weight HistoryWeight History Highest and lowest adult weightsHighest and lowest adult weights Recent weight changesRecent weight changes Perceived “ideal” weightPerceived “ideal” weight

Eating Behaviors Eating Behaviors Attempts to restrict intake (diet pill use, Attempts to restrict intake (diet pill use,

skip meals, limit amounts or types of food, skip meals, limit amounts or types of food, counting fat/CHO grams, counting kcal)counting fat/CHO grams, counting kcal)

Binge Eating (objective vs subjective)Binge Eating (objective vs subjective)

Ask About:Ask About:

Attempts to “compensate” for intake Attempts to “compensate” for intake Self-induced vomiting (*ask about use of Self-induced vomiting (*ask about use of

Ipecac syrup)Ipecac syrup) Laxative abuseLaxative abuse Diuretic abuseDiuretic abuse Driven exerciseDriven exercise

Body ImageBody Image

Ask About:Ask About: Menstrual historyMenstrual history

Review of Systems Review of Systems (dizziness, fainting, (dizziness, fainting, weakness, fatigue)weakness, fatigue)

Psychiatric Symptoms Psychiatric Symptoms (depressed mood, (depressed mood, self-harm ideations, self-harm behaviors, self-harm ideations, self-harm behaviors, anxiety, neurovegetative symptoms)anxiety, neurovegetative symptoms)

Substance Use, past and currentSubstance Use, past and current

Medical assessmentMedical assessment

Physical Exam, review of systemsPhysical Exam, review of systems Medical history, weight historyMedical history, weight history Medication use, substance useMedication use, substance use Vital signs, laboratory testing, EKGVital signs, laboratory testing, EKG

Common Medical IssuesCommon Medical Issues

CardiovascularCardiovascular Orthostatic hypotension (starvation)Orthostatic hypotension (starvation) Bradycardia (starvation)Bradycardia (starvation) Prolonged QTc and T-wave abnormalities Prolonged QTc and T-wave abnormalities

on EKG (purging behaviors)on EKG (purging behaviors) Mitral valve prolapse (diminished muscle Mitral valve prolapse (diminished muscle

mass)mass) Cardiomyopathy (Ipecac)Cardiomyopathy (Ipecac)

Medical Issues (continued)Medical Issues (continued)

Cell countsCell counts Low WBC (starvation and stress)Low WBC (starvation and stress) Anemia (starvation)Anemia (starvation)

Fluid and electrolytesFluid and electrolytes Dehydration (starvation, purging)Dehydration (starvation, purging) Decreased albumin (starvation)Decreased albumin (starvation) Peripheral edema and effusions Peripheral edema and effusions

(starvation)(starvation) Electrolyte disturbances (purging)Electrolyte disturbances (purging)

Medical issues (continued)Medical issues (continued)

RenalRenal Acid-base disturbances (purging)Acid-base disturbances (purging) Impaired concentrating ability Impaired concentrating ability

BoneBone OsteopeniaOsteopenia OsteoporosisOsteoporosis

Medical Issues (continued)Medical Issues (continued)

EndocrineEndocrine Hypoglycemia (starvation)Hypoglycemia (starvation) Hypothermia (starvation)Hypothermia (starvation) Thyroid abnormalities (starvation, stress)Thyroid abnormalities (starvation, stress) Amenorrhea and decreased sex hormone Amenorrhea and decreased sex hormone

levels (starvation, stress)levels (starvation, stress)

Medical issues (continued)Medical issues (continued)

GastrointestinalGastrointestinal Bloating, nausea (starvation)Bloating, nausea (starvation) Elevated liver enzymes (starvation, Elevated liver enzymes (starvation,

refeeding)refeeding) Elevated cholesterol (starvation)Elevated cholesterol (starvation) Constipation and decreased motility Constipation and decreased motility

(starvation)(starvation) Esophageal tears (purging)Esophageal tears (purging)

Medical issues (continued)Medical issues (continued)

DermatologicDermatologic Hair loss (stress, starvation)Hair loss (stress, starvation) Dull hair (decreased fat)Dull hair (decreased fat) Lanugo hair (starvation)Lanugo hair (starvation) Dry skin (decreased fat)Dry skin (decreased fat) Calloused or scarred knuckles (purging)Calloused or scarred knuckles (purging) Acrocyanosis (starvation)Acrocyanosis (starvation)

Dental (purging)Dental (purging)

Other causes of weight loss . . .Other causes of weight loss . . .

Thyroid diseaseThyroid disease Adrenal diseaseAdrenal disease GI disease (motility problems, IBD, celiac GI disease (motility problems, IBD, celiac

disease)disease) MalignanciesMalignancies InfectionInfection . . . and other rare entities . . .. . . and other rare entities . . .

Nutrition needsNutrition needs Refeeding: Refeeding: start with 30-35 kcal/kg, then start with 30-35 kcal/kg, then

increase by around 300 kcal every three days to increase by around 300 kcal every three days to achieve gain of 1-2 kg per week as inpatient, achieve gain of 1-2 kg per week as inpatient, 0.5-1 kg per week as outpatient. (Diet 55-60% 0.5-1 kg per week as outpatient. (Diet 55-60% CHO, <30% fat, meet calculated protein needs)CHO, <30% fat, meet calculated protein needs)

Starved patients becomeStarved patients become hypermetabolic, hypermetabolic, often requiring 60-100 kcal/kg per day to gain often requiring 60-100 kcal/kg per day to gain and maintain.and maintain.

Hypermetabolic state may persist for 6-12 Hypermetabolic state may persist for 6-12 months after weight recoverymonths after weight recovery

Assessment done. Now what?Assessment done. Now what?

Indications for Inpatient Indications for Inpatient CareCareParameterParameter APAAPA AAPAAP% IBW% IBW < 75% definite < 75% definite

inpatientinpatient

< 85% highly < 85% highly structured structured

<75% or ongoing wt <75% or ongoing wt loss despite intensive loss despite intensive mgt mgt

Orthostatic Orthostatic hypotensionhypotension

> 20 bpm> 20 bpm

> 20 mm Hg> 20 mm Hg> 20 bpm> 20 bpm

> 10 mm Hg> 10 mm Hg

BradycardiaBradycardia < 40 bpm< 40 bpm

(in 40s for children)(in 40s for children)< 50 bpm day< 50 bpm day

< 45 bpm night< 45 bpm night

Blood Blood pressurepressure

< 90/60 mm Hg< 90/60 mm Hg

< 80/50 (children)< 80/50 (children)Systolic < 90 mm HgSystolic < 90 mm Hg

TemperatureTemperature < 97 deg< 97 deg <96 deg<96 deg

Body fat %Body fat % __________________ < 10%< 10%

Other Indications for Inpatient Other Indications for Inpatient CareCare

SyncopeSyncope Serum potassium < 3.2 mmol/LSerum potassium < 3.2 mmol/L Serum chloride < 88 mmol/LSerum chloride < 88 mmol/L Esophageal tearsEsophageal tears Cardiac arrhythmias, including prolonged QTc Cardiac arrhythmias, including prolonged QTc

intervalinterval Intractable vomitingIntractable vomiting HematemesisHematemesis Failure to respond to outpatient treatmentFailure to respond to outpatient treatment Severity of psychiatric comorbidities (Major Severity of psychiatric comorbidities (Major

depression, anxiety disorders, substance depression, anxiety disorders, substance abuse disorders)abuse disorders)

Indications for Partial Indications for Partial HospitalizationHospitalization

Individual does not require Individual does not require inpatient care but has not made inpatient care but has not made progress in less intensive treatment progress in less intensive treatment setting OR transitioning from setting OR transitioning from inpatient careinpatient care

Indications for outpatient Indications for outpatient carecare

Individual is above 75% IBW, medically Individual is above 75% IBW, medically stable, appropriate with self-care, and stable, appropriate with self-care, and motivated for treatmentmotivated for treatment

No adequate trial of outpatient care (a No adequate trial of outpatient care (a team including Family/Individual therapist, team including Family/Individual therapist, PCP, Psychiatrist and Nutritionist)PCP, Psychiatrist and Nutritionist)

Medical and psychiatric comorbidities are Medical and psychiatric comorbidities are stabilized or can be managed in an stabilized or can be managed in an outpatient setting.outpatient setting.

A word on medications . . .A word on medications . . .

Psychotropic MedicationPsychotropic Medication

Stay away fromStay away from StimulantsStimulants BuproprionBuproprion TCA’sTCA’s Megace/appetite stimulantsMegace/appetite stimulants

Nutrition remains the key Nutrition remains the key “medication”“medication”

Anorexia NervosaAnorexia Nervosa

Some evidence of lower relapse rates with Some evidence of lower relapse rates with use of SSRI’s once weight-recovereduse of SSRI’s once weight-recovered

SSRI’s are ineffective at low weights, but may SSRI’s are ineffective at low weights, but may begin to exert some effect once patient has begin to exert some effect once patient has progressed beyond 80% of IBWprogressed beyond 80% of IBW

Typical antipsychotics, lithium, Typical antipsychotics, lithium, anticonvulsants, opioid antagonists, appetite anticonvulsants, opioid antagonists, appetite stimulants do not appear to be effectivestimulants do not appear to be effective

Bulimia NervosaBulimia Nervosa

SSRI’s at higher doses seem to SSRI’s at higher doses seem to decrease binge/purge behaviors decrease binge/purge behaviors independent of their efficacy with regard independent of their efficacy with regard to depressive symptomsto depressive symptoms

Some data support decreased Some data support decreased binge/purge frequency with topiramate binge/purge frequency with topiramate but side effects are common, weight but side effects are common, weight loss commonloss common

Best Practices Treatment Best Practices Treatment GuidelinesGuidelines

American Psychiatric AssociationAmerican Psychiatric Associationhttp://www.psych.org/psych_pract/treatghttp://www.psych.org/psych_pract/treatg

American Academy of PediatricsAmerican Academy of Pediatrics NICE guidelines (UK)NICE guidelines (UK)

http://www.nice.org.ukhttp://www.nice.org.uk

ResourcesResources

www.nationaleatingdisorders.orgwww.nationaleatingdisorders.org www.aedweb.orgwww.aedweb.org www.edauk.comwww.edauk.com www.anad.orgwww.anad.org www.somethingfishy.orgwww.somethingfishy.org

UNC Hospitals ED program (919)966-UNC Hospitals ED program (919)966-70127012