Speaker: Implement clinical considerations in treatment of common eating disorders

Clinicians should implement specific evidence-based treatments for various eating disorders, according to a presenter at the NEI Max Virtual Conference.

Leslie Citrome, MD, MPH, clinical professor of psychiatry and behavioral sciences at New York Medical College, provided an overview of treatment for three eating disorders that occur mainly in adults: anorexia nervosa, bulimia nervosa and binge eating disorder.

“Anorexia nervosa is characterized by an intense fear of weight gain and a very disturbed body image, which motivates very severe dietary restriction,” Citrome said. “What’s remarkable is that there are significant cognitive distortions and cognitive emotional functioning that is markedly disturbed. Serious medical morbidity and psychiatric comorbidity are common and actually expected with anorexia nervosa, and it has a relapsing and protracted course that is very difficult to treat.”

According to Citrome, the DSM-5 does not require the presence of amenorrhea for the diagnosis of anorexia nervosa. Assessments for diagnosing this disorder include psychological and physical evaluations. Psychological and behavioral interventions form the “core” of treatment, Citrome said, but nutritional interventions remain necessary. However, pharmacological interventions play a limited role aside from treating comorbidities.

For adolescent anorexia nervosa, family-based treatment and Maudsley family therapy have strong evidence. For adult anorexia nervosa, studies have not produced strong evidence for significant beneficial effect of interventions, but enhanced cognitive behavioral therapy, focal psychodynamic psychotherapy, Maudsley model of anorexia nervosa treatment for adults and specialist supportive clinical management have moderate evidence of efficacy.

Both binge-eating disorder and bulimia nervosa are more common than anorexia nervosa, with 12-month prevalence rates of 0.44%, 0.14% and 0.05%, respectively, according to data from the 2012 to 2013 National Epidemiologic Survey on Alcohol and Related Conditions. Although binge-eating disorder and bulimia nervosa are similar, they also have important differences highlighted in DSM-5 diagnostic criteria. Both involved binge eating with loss of control, but bulimia nervosa involves regular compensatory behaviors and requirement of overconcern for shape and weight, whereas binge-eating disorder does not.

Both disorders have similar psychological and behavioral interventions available, the primary of which is CBT. However, pharmacological interventions differ, with fluoxetine the only FDA-approved medication for bulimia nervosa, and it is often prescribed at higher does than those used to treat major depressive disorder. For binge-eating disorder, lisdexamfetamine is the only FDA-approved medication currently available. There are no FDA-approved medication treatments for anorexia nervosa.

According to Citrome, binge-eating disorder is considered an “invisible disorder,” since it is often kept secret, accompanied by shame, may be an unknown disorder to individuals who have it and is an under-recognized disorder to clinicians. According to data of 22,397 respondents to an online survey, 344 met DSM-5 criteria for binge-eating disorder in the past 12 months but 11 (3.2%) had been diagnosed with the disorder by a health care provider. Treating binge-eating disorder can be complicated by miscommunication regarding the severity of episodes, as well as bias, judgment and shame related to the disorder, Citrome said. When discussing the disorder with a patient, Citrome advised clinicians to use words such as weight and BMI and descriptions such as “kept eating even though not physically hungry” and “loss of control.” Words to avoid include fatness, excess fat, large size, heaviness, obesity and willpower.

Sharing the DSM-5 diagnostic criteria of this disorder with patients may be a helpful tool for clinicians, Citrome said, as it allows them to fell validated in that these symptoms are real.

Psychiatric comorbidities are common for binge-eating disorder, with 80% of patients meeting the criteria for mood disorders, anxiety disorder, substance use or ADD. Further, suicide attempt risk is elevated among this patient population.

Aside from lisdexamfetamine, other pharmacologic treatments for binge-eating disorder include antidepressants, anticonvulsants, anti-obesity agents that target appetite and weight, medications for addictive disorders and dual-acting dopamine and norepinephrine reuptake inhibitors.

“Anorexia nervosa and bulimia nervosa are associated with behaviors that are more difficult to hide, but binge-eating disorder is easy to hide, so patients with this disorder are often unrecognized and untreated,” Citrome said.