RISK FACTORS:Depression, obsessionality, impulsivity, Low self-esteem, Achievement pressure; high self-expectations; social anxiety, Acceptance of the culturally condoned ideal of slimness, Ambivalence about dependence/independence
GENERAL MEASURES:
. INPATIENT :
. If possible, admit to eating disorders unit or unit with structured eating disorders program
. Supervised meals and bathroom privileges
. No access to the bathroom for 2 hours after meals
. Monitor weight and physical activity
. Assess psychological state and nutritional status
. Identify precipitants to bingeing
. Develop alternatives to purging
. Monitor electrolytes
. Focal individual and cognitive behavioral therapy. Frequent visits by physician.
. Gradually shift control to patient as she demonstrates responsibility
. OUT PATIENT:
. Build trust, treatment alliance
. Assess psychological state and nutritional status
. Involve patient in establishing target goals
. Use self-monitoring techniques such as food diary
. Identify prodromal states, precipitants
. Address ruminations about calories, weight, purging
. Focus on overall well-being, developing gratifying relationships
. Challenge fear of loss of control
. Cognitive-behavioral therapy and interpersonal therapy
. Family therapy for adolescents
. Nutritional education, relaxation techniques, couples
DRUG(S) OF CHOICE:
β’ SSRIs - fl uoxetine (Prozac) 10-80 mg or fl uvoxamine (Luvox) 50-300 mg/day are effective in reducing
symptoms with relatively few side effects. High dose treatment often needed.
β’ MAO inhibitors - phenelzine (Nardil) 60-90 mg/day. Patients with atypical depression may respond to MAO
inhibitors and not SSRIs.
β’ Augment with buspirone (BuSpar) if desired. To prevent relapse, maintain antidepressant medication at full
therapeutic dose for at least one year.
β’ Note: Dishonesty and noncompliance are common therapy, self-help group may also be helpful.
Significant possible interactions:
β’ Lithium and tricyclic medication can be lethal when administered to hypokalemic patients
β’ SSRIs may increase tricyclic levels
β’ Because of danger of food related hypertensive crises, use irreversible MAO inhibitors only with fully cooperative patients
β’ To avoid the serotonin syndrome, allow 5 weeks between discontinuing fl uoxetine and beginning MAO
inhibitor
β’ Avoid co-administration of bupropion (Wellbutrin, Zyban) as this may precipitate seizures
PATIENT MONITORING:
β’ Binge-purge activity
β’ Level of exercise activity
β’ Self-esteem, comfort with body and self
β’ Ruminations and depression
β’ Repeat any abnormal lab values weekly or monthly until stable
PREVENTION/AVOIDANCE:
β’ Encourage rational attitude about weight
β’ Moderate overly high self-expectations
β’ Enhance self-esteem
β’ Diminish stress
POSSIBLE COMPLICATIONS:
β’ Suicide
β’ Drug and alcohol abuse
β’ Potassium depletion; cardiac arrhythmia; cardiac arrest
β’ Maternal and fetal problems if pregnant
EXPECTED COURSE/PROGNOSIS:
β’ Highly variable, tends to wax and wane
β’ May spontaneously remit
β’ Most patients continue to binge/purge, but do so less often
β’ Patients who do not establish trust likely to drop out of therapy, be lost to follow-up
β’ Those who stay in therapy tend to improve
β’ Patients with personality disorders have a generally poor prognosis
β’ 30-50% relapse rate per year for several years
β’ Impulsive patients may engage in stealing, suicide gestures, substance abuse, promiscuity
OTHER NOTES:
. Anorexic patients may deal with the frustration of chronic food deprivation by converting to bulimia
. High risk
. Ballet dancers, models, cheerleaders
. Athletes, especially runners, gymnasts, weight lifters, body builders, jockeys, divers, wrestlers, fi gure skaters,
field hockey players
. Sub-clinical eating disorders are common in university populations
. Sexual abuse is not causally related to bulimia
. Chronic, extreme hypokalemia can occur without physical symptoms