Why do certain Americans starve themselves, others binge eat and purge,
and still others only binge eat? The answers are not clear. Still, some
effective eating disorder treatments are available, and others may be
Walter Kaye, M.D.: “Genes play a much stronger role in anorexia
nervosa than initially thought.” Photo courtesy of the University of
Pittsburgh Medical Center
Terri M. was a “terrific young girl” with a perfectionist
personality who developed early symptoms of exercising anorexia nervosa at age
8. Three years later, she had full-blown anorexia, Joel Yager, M.D., a
professor of psychiatry at the University of New Mexico and an eating disorder
authority, recalled in an interview with Psychiatric News.
“Her mother had also had the disorder in college,” Yager added.“
Both her mother and father are thin, high-achieving compulsive athletes
to this day, as are all of their friends.”
Can Terri's anorexia nervosa be blamed on genes? The influence of her
parents? Or other factors? Probably all three, research results suggest,“
although genes play a much stronger role in anorexia nervosa than
initially thought,” Walter Kaye, M.D., a professor of psychiatry at the
University of Pittsburgh and an anorexia expert, told Psychiatric
Nonetheless, there are still a number of puzzling questions about the
origins of anorexia nervosa, a condition that has been medically recognized
since the late 19th century. In fact, a lot still remains to be learned not
just about the sources of anorexia nervosa, but also about those of the two
other recognized eating maladies— bulimia nervosa, first identified in
1979 and included in DSM-III, and binge-eating disorder, included in
the DSM-IV as a provisional disorder.
For instance, ample evidence has revealed that eating disorders occur
predominantly in developed countries, prompting eating-disorder experts to
suspect that certain cultural or social factors in developed countries are at
least partially responsible for the illnesses. Yet little research has
divulged which cultural or social factors might be the culprits.
Moreover, there are no firm data about the prevalence of eating disorders
in the United States and thus no way of knowing whether the prevalence of
eating disorders has changed in recent years.
“I wish we had such data,” said David Herzog, M.D., a professor
of psychiatry at Harvard Medical School and an eating disorder authority.“
It is a limitation in our field.”
In fact, it is not even known whether more Americans are seeking treatment
for eating disorders today than five or 10 years ago. “I am not aware of
any data to show changing trends in help-seeking behavior,” said Yager.“
This is very complex and has to do with changing awareness—which
might increase help-seeking behavior—and issues concerning access to
care, both availability of trained specialists and insurance or other means to
pay for care.”
The good news, however, is that there are more ways to help individuals
with eating disorders today than there were 20 years ago.
For instance, there is strong evidence to support the value of family
involvement in the treatment of anorexia nervosa patients under the age of 18.
It is also now known that after anorexia nervosa patients have regained
weight—with the help of families and/or with the help of staff in eating
disorders programs—that the risk of relapse can be reduced with
psychotherapy, particularly cognitive-behavioral therapy (CBT), and with
fluoxetine, and presumably other SSRI antidepressants as well, said Yager.
The treatment of choice for bulimia nervosa is CBT, whose effectiveness is
now supported by more than a dozen studies. Scientific evidence has also
revealed that if bulimia nervosa patients are treated with both CBT and an
SSRI, they do even better than if they get CBT alone, Yager said.
As for binge-eating disorder, CBT is quite successful is halting the
binging, but it is not so effective in helping people achieve a healthy weight
over the long term, according to James Mitchell, M.D., president of the
Neuropsychiatric Research Institute at the University of North Dakota.
Still other effective therapies for eating disorders may become available
soon as scientists make inroads in understanding the illnesses.
A case in point: Kaye and his coworkers recently found that two types of
dopamine receptors—D2 and D3—are more active
in the basal ganglia area of the brains of anorexia nervosa subjects than in
the basal ganglia area of the brains of subjects who don't have the illness.
The researchers also found that the gene that makes the D2
receptors is abnormal in some anorexia nervosa subjects. Kaye and his group
thus suspect that dopamine overactivity may underlie anorexia nervosa and that
medications that block dopamine receptors in the brain—say,
second-generation antipsychotics—might be of some benefit to persons
with the illness. The second-generation antipsychotics are also known to
promote weight gain, which patients with anorexia nervosa desperately
However, “there have not been any double-blind, placebo-controlled
trials of atypical antipsychotic medications in anorexia nervosa
subjects,” Kaye said. “That is one thing that really needs to be
Yager agreed. “We know that some clinicians are starting to use
atypical antipsychotic medications to help facilitate weight gain in
malnourished anorexia nervosa patients, but we still lack both controlled
trials and long-term studies to show whether these have any true added value
and/or sustaining power that may outweigh potential adverse reactions to
taking these medications. Thus, during the next five or 10 years, we can
anticipate trials of atypical antipsychotics for acute anorexia
Regarding promising new treatments for bulimia nervosa, Mitchell and
colleagues conducted a study of 117 subjects with the disorder to see whether
conducting CBT via telepsychiatry is as effective, and as acceptable, as when
it is conducted face to face. The answer was yes on both counts, Mitchell
reported at APA's 2005 annual meeting in May.
Regarding propitious new therapies for binge-eating disorder, Susan
McElroy, M.D., a professor of psychiatry at the University of Cincinnati, and
coworkers enrolled 61 obese subjects with binge-eating disorder in a 14-week
randomized, double-blind, placebo-controlled study in which subjects received
either the anticonvulsant topiramate or a placebo. Those who completed the
study were also offered participation in a 42-week, open-label extension trial
Forty-three subjects from both the double-blind study and the open-label
trial provided outcome measures. The average duration of topiramate treatment
was 21 weeks. From baseline to outcome, all of them experienced a significant
decrease in binge eating and in weight, McElroy and her team reported in the
November 2004 Journal of Clinical Psychiatry.
Nonetheless, the researchers admitted, a fairly large number of subjects
dropped out of their study and trial, either because of protocol nonadherence
or because of adverse side effects from topiramate.
Noncompliance can also pose a dilemma in anorexia nervosa trials. For
example, Katherine Halmi, M.D., a professor of psychiatry at Weill Cornell
Medical College, and colleagues enrolled 122 patients with the illness in a
study in which subjects received CBT, an SSRI antidepressant, or both for a
year. The dropout rate was 56 out of 122, or 46 percent, they reported in the
July Archives of General Psychiatry.
Sometimes it is difficult to get eating-disorder patients to enter
treatment trials in the first place. For instance, several years ago Michael
Devlin, M.D., clinical codirector of eating disorders research at New York
State Psychiatric Institute, and coworkers attempted to recruit obese
individuals with a binge-eating problem into a treatment trial in which CBT or
an SSRI would be tested as add-on therapy to a more traditional weight-loss
program. The program emphasized mostly healthy eating, a healthy lifestyle,
self-acceptance, and, to a lesser degree, weight loss.
“Often they would call up, express interest, make an appointment for
intake, but then wouldn't show up,” Devlin said in an interview. The
reason why, he suspected, is that “many obese people have had so many
disappointing experiences with dieting that they feel very
Often individuals with eating disorders do not want treatment at all. This
is especially true for persons with anorexia nervosa who are over 18 years of
age, Halmi told Psychiatric News. That is why treating them before
they turn 18 is so crucial, she explained, and why family involvement in
treatment before they turn 18—the age of majority—is also so
Thus, finding some way to motivate eating-disorder patients both to seek
treatment and to stick with it would surely constitute a“
breakthrough” in the conquest of eating disorders. And when all
is said and done, motivation may be as crucial as treatment per se.
Take the case of 35-year-old “Cindy T.,” who had anorexia
nervosa since age 13. She had osteoporosis, had lost most of her teeth, and
had been close to dying on several occasions. “A lot of people had given
up on her,” Mitchell said. “But she eventually recovered and is
doing very well now.”
“Part of the reason why she did recover,” Mitchell observed,“
was her own motivation to change. She was tired of living her life that
way and made a commitment to do things differently.” ▪