This document summarizes the assessment and treatment of various eating disorders including anorexia nervosa, bulimia nervosa, binge eating disorder, and obesity. It discusses the evaluation of medical, psychiatric, and safety status. Treatment involves restoring healthy weight and treating complications through a coordinated care approach using psychotropic medications, psychotherapy, nutritional counseling, and management of medical issues. Pharmacological interventions discussed for different eating disorders include SSRIs, atypical antipsychotics, topiramate, and cyproheptadine.

1. By Heba Essawy
Prof Of Psychiatry

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.  Affective and anxiety disorders .
 Obsessive compulsive disorders, impulse
control disorders .
 Psychosis .
 Substance use disorders.
 Pain Disorder.

4.  Complex process
-Psychotropic drugs
-Psychotherapy
-Nutritional counseling,
-Treatment of medical complications.

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. 1.Outpatient
2.Partial hospitalization (full-day outpatient care)
3.Residential treatment center
4.Inpatient hospitalization

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.  Serious concurrent medical problems
-Metabolic abnormalities.
- Hematemesis.
- Uncontrolled vomiting
 Serious psychiatric disturbances
- Suicidality.
- Other psychiatric diagnosis.
- Severe alcohol or drug dependence .

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. 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.  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. - 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. 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.  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.  Effectiveness for sertraline regarding
- Depressive symptoms
- Not concerning weight gain
(Santonastaso et al., 2001)

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.  Antidepressants :
may be used in AN
-with depressive symptomatology
- with comorbid obsessive disorder
- Not in general.

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.  SULPIRIDE :
- No statistical sig. over placebo .
 PIMOZIDE:
- Induce weight gain ?.
Vandereycken (1984)

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.  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.  AMISULPRIDE : promising results with
combination with fluoxetine.
( Ruggiero et al. (2001)
 ARIPIPRAZOLE : need longer period time
( Trunke et al. (2010)

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.  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.  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.  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. recombinant human growth hormone (rhGH) :
 No weight gain between pharmacological group
and placebo group
(Hill et al. (2000)

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.  No clear evidence to recommend the
addition of pharmacotherapy to
psychotherapy in AN with comorbidities
- depression.
-obsessions.
- compulsions.
- anxiety.

30.  Imipramine: reduce bulimic behaviour .
 Amitryptiline :with no clear evidence of
superiority only in the depressive subgroup.
 Desipramine: reduce bulimic behaviour.

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.  Moclobemide
shows no efficacy in BN in 1 RCT .
 Phenelzine
shows an efficacy concerning bulimic
behaviour ( Cheese reaction ) ( Not
recommended )

33.  No RCT, no evidence for
-Duloxetine.
-Bupropion
- Lithium
- Trazodone
- Mianserin
-Carbamazepine
- Oxcarbamazepine

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.  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.  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.  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.  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.  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.  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.  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.  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.  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. 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. 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.  Antideprasant
Imipramine.
Citalopram- ecitalopram.
Sertraline.
 Mood stabilizer
Topiramate
 Atomoxitine.
 Sibutramine.

47. Thank s a lot

48. Antideprasants: Fluxetine
Mirtazapine
Antipsychotics olanzapine
Resperidone
Quetiapen
Antihistaminic Cyproheptadine
supplements Zinc