Anorexia nervosa (AN) is a severe, potentially lethal disorder that predominantly affects young women. AN causes significant adverse effects on physical health, as well as impairing social and occupational functioning.
Ms. B. is a 22-year-old university student who consults you at her family’s insistence because of progressive weight loss over the past 2 years. Ms. B. is 157 cm (62 in) tall and weighs 39 kg (85 lb), with a body mass index of 15.5, and has not had menses for the past 7 months. She acknowledges that she is thin but is extremely fearful of gaining weight and restricts herself to a maximum intake of 2000 kJ (500 kcal) per day. She also engages in 2 hours of daily intense physical activity but denies bingeing, laxative abuse, diuretic abuse or self-induced vomiting. She has no physical symptoms other than fatigue and hypothermia and no psychiatric symptoms other than irritability and mild mood lability. She is withdrawn socially, but she continues to get good marks in school.
Ms. B. fulfills the criteria for the restricting subtype of AN with no evidence of significant axis I psychiatric comorbidity. The recommended intervention for Ms. B. would be intensive structured treatment aimed at weight restoration, either as a hospital inpatient or as a patient at a day hospital. Medications would not be included in the initial treatment plan, because they are unlikely to be effective in the weight restoration phase of treatment.
Although several classes of drugs have been tried as therapy for AN, to date no medication, alone or in combination with other therapies, has been demonstrated to be effective in the treatment of the primary disorder. Moreover, the subtype, whether binge-eating/purging or restricting, does not appear to have an impact on the response to pharmacotherapy.
Whereas antidepressants have not been proven to be useful in promoting weight gain, they can play a role in the treatment of clinically significant comorbid conditions, such as major depression, obsessive–compulsive disorder or other anxiety disorders. Furthermore, there is evidence to suggest that selective serotonin reuptake inhibitors may help prevent relapse in at least some patients with AN once weight restoration has been achieved.
Recent reports that atypical antipsychotics, such as olanzapine, facilitate weight restoration and decrease eating-focused and weight-focused anxiety and obsessionality remain to be confirmed by randomized, placebo-controlled, double-blind studies. Atypical antipsychotic agents should therefore not be used as a first-line treatment but could be tried in patients whose condition is refractory to treatment or in high-risk patients. Of note are the difficulties encountered by clinicians when trying to convince patients with AN, with their intense fear of loss of control over weight gain, to accept treatment with drugs known to directly cause weight gain.
Finally, when treating the comorbidity or medical complications of AN, cardiac and liver functions should be monitored and caution should be exercised in the use of drugs that may compromise cardiac function. Drugs that prolong the QT interval or that lower the seizure threshold (such as bupropion) should also be avoided.
Footnotes
To submit questions for this regular feature, please send them to the editors-in-chief at jpn{at}cma.ca. Please include details of any relevant case and your name, address, telephone and fax numbers as well as your email address.
The information in this column is not intended as a definitive treatment strategy but as a suggested approach for clinicians treating patients with similar histories. Individual cases may vary and should be evaluated carefully before treatment is provided.
Competing interests: Dr. Israël has received speaker fees from Lundbeck.