Guide lines for Treating Eating Disorder

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anorexia nervosa, bulimia nervosa, binge eating disorder, evidenced based studies, guidelines , paroxetine,

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Guide lines for Treating Eating Disorder

  1. 1. By Heba Essawy Prof Of Psychiatry
  2. 2.  Eating disorders including: •Anorexia nervosa.(AN) •Bulimia nervosa. (BN) •Eating disorder not otherwise specified Binge eating disorder.(BED) Night eating syndrome.(NED) * Obesity.
  3. 3.  Affective and anxiety disorders .  Obsessive compulsive disorders, impulse control disorders .  Psychosis .  Substance use disorders.  Pain Disorder.
  4. 4.  Complex process -Psychotropic drugs -Psychotherapy -Nutritional counseling, -Treatment of medical complications.
  5. 5. A .Coordinating Care and Collaborating with Other Clinicians. B .Assessing and Monitoring Eating Disorder Symptoms and Behaviors. c. Assessing and Monitoring the Patient's General Medical Condition. d. Assessing and Monitoring the Patient's Safety and Psychiatric Status. E-Providing Family Assessment and Treatment
  6. 6. 1.Outpatient 2.Partial hospitalization (full-day outpatient care) 3.Residential treatment center 4.Inpatient hospitalization
  7. 7. Before the onset of medical instability.  Abnormalities in vital signs -Marked orthostatic hypotension -Increase in pulse of 20 bpm. -Drop in standing bl pr. 20mmHg. -Bradycardia <40 bpm. -Tachycardia >110 bpm. - Hypothermia.
  8. 8.  Serious concurrent medical problems -Metabolic abnormalities. - Hematemesis. - Uncontrolled vomiting  Serious psychiatric disturbances - Suicidality. - Other psychiatric diagnosis. - Severe alcohol or drug dependence .
  9. 9. 1) Restore patients to a healthy weight: * with the return of menses *normal ovulation in female patients. * normal sexual drive and hormone levels in male . * normal physical and sexual growth in children. 2) Treat physical complications. 3) Enhance motivation to enhance healthy Eating patterns . 4) Education for healthy Nutrition and Eating patterns.
  10. 10. 5) Change core dysfunctional cognitions, attitudes, motives, conflicts. 6) Treat associated psychiatric conditions, mood and impulse and self-esteem and behavioral problems 7) Provide family counseling. 8) Prevent Relapse.
  11. 11.  The rationale for treating AN (1) Dysfunction in the serotonergic and noradrenergic system in the pathophysiology (2) Comorbidity with * Anxiety disorders. *Obsessive compulsive *Depression.
  12. 12. - Clomipramine: increased hunger, appetite and energy intake, but no weight gain. (Lacey and Crisp (1980) ) - Amitriptyline : No significant weight gain. (Biederman et al. (1985)) No clear evidence for the general use of tricyclic in AN except for depression.
  13. 13. Open randomized study of Fassino(2002)  No differences in BMI or weight gain .  Improvement in : - Depression. - Obsessive-compulsive symptoms. - Impulsiveness -Trait-anger in AN-R type.
  14. 14.  Gwirtsman et al.(1990) : diminished depressive symptoms was associated with weight gain.  Kaye et al. (2001): patients on fluoxetine(1 year): reducion in relapse rate increase weight and reduction of symptoms.  Walsh et al.(2006a) : No benefit from fluoxetine in reducing relapse rate AN but ttt obsessive symptoms.
  15. 15.  Effectiveness for sertraline regarding - Depressive symptoms - Not concerning weight gain (Santonastaso et al., 2001)
  16. 16.  Efficacious with long-standing AN .  After 9-month follow-up : -weight gain . - improve mood.  Mirtazapine: for older, chronically ill patients comorbid depression. ( Safer et al. (2010))
  17. 17.  Antidepressants : may be used in AN -with depressive symptomatology - with comorbid obsessive disorder - Not in general.
  18. 18.  Cassano et al. (2003) report an open trial with haloperidol AN-R over 6 month. Haloperidol - might be effective as adjunct treatment for AN-R ( severe cases) .
  19. 19.  SULPIRIDE : - No statistical sig. over placebo .  PIMOZIDE: - Induce weight gain ?. Vandereycken (1984)
  20. 20.  Promising weight gain & psychopathological improvement in AN (Barbarich et al., 2004)  Reduced anorexic ruminations but no difference in BMI (Mondraty et al. (2005).  Superior for rate of weight gain,  Early achievement of target BMI  Early in reduction of obsessive (Bissada et al. (2008).  Olanzapine** seems to be a promising in AN–BP type.
  21. 21.  RISPERIDONE* may be useful in AN . (Newman-Toker, 2000)  QUETIAPINE* :Low-dose (100-400mg) resulted in both psychological and physical improvements, with minimal side-effects. (Court et al. (2010))
  22. 22.  AMISULPRIDE : promising results with combination with fluoxetine. ( Ruggiero et al. (2001)  ARIPIPRAZOLE : need longer period time ( Trunke et al. (2010)
  23. 23. Cyproheptadine:  Effective in severely ill AN patient in weight gain.  Increased weight gain in non-bulimic group and impaired treatment in bulimic group. (Bartra et al., 2006).
  24. 24.  Zinc** : in Adolescent with AN at risk for zinc deficiency , good respond after zinc supplementation (50 mg elemental zinc/day). (Safai-Kutti (1990)  Oral administration of 14 mg of elemental zinc daily for 2 months in AN is routine. (Birmingham (2006))
  25. 25.  Lithium : -One RCT found no efficacy for Lithium over placebo. -One RCT found efficacy over placebo concerning binges or purges. (Gross et al. (1981) - Cisapride: concerning gastric emptying are conflicting. Whereas one study found no efficacy over placebo, 1 study found a difference for gastric emptying. (Category grade E evidence).
  26. 26.  Naltrexone : - Auto-addiction model for AN and BN - 100 mg naltrexone twice a day with for 6 weeks . - Decrease Binge and Purging behaviour AN and BN. -No weight restoration in AN in week 6. ( Marrazzi et al. (1995))
  27. 27. recombinant human growth hormone (rhGH) :  No weight gain between pharmacological group and placebo group (Hill et al. (2000)
  28. 28.  Weight gain was 39% higher in the tube group than in the control group.  After discharge the relapse free period was longer in the tube group. ( Rigaud et al. (2007) .
  29. 29.  No clear evidence to recommend the addition of pharmacotherapy to psychotherapy in AN with comorbidities - depression. -obsessions. - compulsions. - anxiety.
  30. 30.  Imipramine: reduce bulimic behaviour .  Amitryptiline :with no clear evidence of superiority only in the depressive subgroup.  Desipramine: reduce bulimic behaviour.
  31. 31.  Citalopram : no clear efficacy in bulimia nervosa over placebo  Fluoxetine***: showing an efficacy over placebo concerning bulimic behaviour.  Fluvoxamine** 3 RCTs with 2 showing efficacy over placebo concerning bulimic behaviour  Sertraline **: one RCT that shows efficacy over placebo concerning bulimic behaviour
  32. 32.  Moclobemide shows no efficacy in BN in 1 RCT .  Phenelzine shows an efficacy concerning bulimic behaviour ( Cheese reaction ) ( Not recommended )
  33. 33.  No RCT, no evidence for -Duloxetine. -Bupropion - Lithium - Trazodone - Mianserin -Carbamazepine - Oxcarbamazepine
  34. 34.  Topiramate*** with efficacy in reducing BN associated psychopathology behaviour. for topiramate in BN, with a moderate risk- benefit ratio.  Naltrexone Inconsistent results  Methylphenidate Inconsistent results  Light therapy in reducing psychopathology in BN.
  35. 35.  Available literature on pharmacological treatment of BN is based on trials of relatively short duration( less 6 months)  No enough information on the long-term efficacy of these treatments.
  36. 36.  Antidepressants ; 3 RCTs 2 with imipramine*** 1 with Desipramine showing a reduction in binge frequency.  Citalopram/escitalopram***: 2 RCTs showing efficacy in BED over placebo .  Fluvoxamine: 3 studies with no favourable results .
  37. 37.  Fluoxetine: there are conflicting results concerning efficacy in BED.  Sertraline*** Effective in 2 RCTs over placebo concerning psychopathology and BE.  Atomoxitine** : one RCT that shows efficacy in BED .  Venlafaxine : One RCT suggests that there might be efficacy in BED.
  38. 38.  Venlafaxine**:effective over placebo.  Sibutramine ***: over placebo in BED but low risk-benefit ratio.  Reboxetine *:in BED .  Topiramate ***: 3 RCTs that suggest efficacy over placebo in BED with moderate risk- benefit ratio.
  39. 39.  Zonisamide ** efficacy in psychopathology, weight and BED behaviour.  Baclofen* : may be helpful in reducing frequency of binge eating.  Orlistat *** : effective in 3 RCTs over placebo in reducing weight in BED with low to moderate risk -benefit ratio.  d-fenfluramin **: efficacy over placebo for in reducing binges per week in BED  Naltroxone **: efficacy over placebo in reducing binge duration in BED .
  40. 40.  The available literature on pharmacological treatment of BED is based on trials of relatively short duration ( less than 6 months )  No enough information on the long-term efficacy of these treatments.
  41. 41.  1.Establishment of healthy target weights  2.Nutritional rehabilitation and refeeding programs  3.Establishment of expected rates of controlled weight gain  4.Setting advancing intake levels  5.Vitamin and mineral supplementation (e.g., phosphorous)  6.Monitoring of serum potassium and rehydration  7.Setting physical activity  8.Other treatments, when indicated, including liquid food supplements; nasogastric feedings; parenteral feedings  9.Monitoring and treatment of symptoms and conditions associated with gaining weight (e.g., anxiety, abdominal pain, constipation)
  42. 42.  1.Family psychotherapy for children and adolescents  2.Family group psychoeducation for adolescents  3.Cognitive-behavioral therapy (CBT) for adults  4.Interpersonal therapy (IPT) and/or psychodynamically oriented individual or group psychotherapy for adults  5.Psychosocial interventions based on addiction models  6.Support groups led by professionals .  7.Internet-based support .  8.Non-verbal therapeutic methods (e.g., creative arts, movement therapy, occupational therapy)
  43. 43.  1) Understand and cooperate with their nutritional and physical rehabilitation.  2) understand and change the behaviors and dysfunctional attitudes related to their eating disorder.  3) improve their interpersonal and social functioning.  4) address comorbid psychopathology and psychological conflicts that reinforce or maintain eating disorder behaviors.
  44. 44. Anorexia Bulimia Ch.by Disturbed body image Binge eating Weight loss  85% of expected. Wt loss  15% Specify type Restricting Purging Binge/Purging Non purging Life time prevailing in female 0.5-3.7% 1-4% Age of onset 10-30ys 16-18ys M:F 1: 10 1:5 Biological etiology MHPG in urine a CST  NE  endorphins  5-HT  endorphins Course 40% recovery relapse in 50% in system 30% improve 30% chance
  45. 45. Anorexia Bulimia Treatment Hospitalization Hospitalization Weight Metabolic alkalosis Metabolic balance Pharmacotherapy Fluoxetine Mirtazapine Fluxetine Fluvoxamine- sertraline Olanazapine, resperidone - quetiepine Topiramate cyproheptadine - Elemental zinc - Psychological Group therapy Individual therapy Cognitive Cognitive
  46. 46.  Antideprasant Imipramine. Citalopram- ecitalopram. Sertraline.  Mood stabilizer Topiramate  Atomoxitine.  Sibutramine.
  47. 47. Thank s a lot
  48. 48. Antideprasants: Fluxetine Mirtazapine Antipsychotics olanzapine Resperidone Quetiapen Antihistaminic Cyproheptadine supplements Zinc

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