Olanzapine treatment of anorexia nervosa: a retrospective study

Efficacy and tolerance of second-generation antipsychotics in anorexia nervosa: A systematic scoping review

INTRODUCTION

Second-generation antipsychotics (SGAs) are frequently prescribed for the treatment of resistant anorexia nervosa. However, few clinical trials have been conducted so far and no pharmacological treatment has yet been approved by the Food and Drug Administration. The aim of this paper is to conduct a systematic scoping review exploring the effectiveness and safety of atypical antipsychotics in anorexia nervosa (AN).

METHOD

We conducted a systematic scoping review of the effectiveness and tolerability of SGAs in the management of AN. We included articles published from January 1, 2000, through September 12, 2022 from the PubMed and PsycInfo databases and a complementary manual search. We selected articles about adolescents and adults treated for AN by four SGAs (risperidone, quetiapine, aripiprazole or olanzapine). This work complies with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews (PRIMA-ScR) and was registered in the Open Science Framework (OSF) repository.

RESULTS

This review included 55 articles: 48 assessing the effectiveness of SGAs in AN and 7 focusing only on their tolerability and safety. Olanzapine is the treatment most frequently prescribed and studied with 7 randomized double-blind controlled trials. Other atypical antipsychotics have been evaluated much less often, such as aripiprazole (no randomized trials), quetiapine (two randomized controlled trials), and risperidone (one randomized controlled trial). These treatments are well tolerated with mild and transient adverse effects in this population at particular somatic risk.

DISCUSSION

Limitations prevent the studies both from reaching conclusive, reliable, robust, and reproducible results and from concluding whether or not SGAs are effective in anorexia nervosa. Nonetheless, they continue to be regularly prescribed in clinical practice. International guidelines suggest that olanzapine and aripiprazole can be interesting in severe or first-line resistant clinical situations.

A review on association and correlation of genetic variants with eating disorders and obesity

Background

Now, eating disorders and obesity and their correlations are danger signal in worldwide which is caused by multifactor and associated with significant mortality and morbidity.

Main body

Every aspect of a patient’s life is influenced by eating disorders and obesity and their correlations. Due to frequent seeing of obese patients, eating disorders have been included in the review as they can sometimes be associated with obesity. However, it should be noted that most patients having eating disorder are at risk to be obese or overweight. This research explores the risk factors for the two disorders, as well as the assessment of medical complications and treatment recommendations for the disorders. In these two disorders, there is also a correlation. The essential consideration is that eating disorders are impulse-control disorders which are similar to addictive behaviors in some aspects. So it is a crying need to treat a patient with obesity and eating disorders simultaneously to ensure success. Genome-wide association studies (GWASs) have increased our knowledge of the pathophysiology of eating disorders (EDs) and obesity and their correlation.

Conclusion

This review enlightens on the summary of eating disorder, obesity, genotypic traits, molecular relations, interaction, correlation, and effect of eating disorder and obesity which outline potential future directions and clinical implications for patients with EDs and obesity.

Short-Term Outcome of Inpatient Treatment for Adolescents with Anorexia Nervosa Using DSM-5 Remission Criteria

This study evaluated the short-term outcome of a multimodal inpatient treatment concept for adolescents with anorexia nervosa (AN). In this prospective observational study, a cohort of 126 female adolescents with AN (age range: 11–17, mean age: 14.83) was longitudinally followed from admission to discharge (average duration of stay: 77 days). We used gold-standard clinical interviews and self-report data, as well as DSM-5 remission criteria, to evaluate the treatment outcome. From admission to discharge, body-mass-index (BMI) significantly improved by 2.6 kg/m². Data from clinical interviews and self-reports yielded similar improvements in restraint eating and eating concerns (large effects). Lower effects were observed for variables assessing weight/shape concerns and drive for thinness. At discharge, 23.2% of patients showed full remission of AN, 31.3% partial remission, and 45.5% no remission according to DSM-5 criteria. Differences in remission groups were found regarding AN severity, age at admission, and use of antidepressant medication. Living with both parents, longer duration of inpatient treatment and the use of antipsychotic medication were significantly associated with higher BMI change. The findings provide evidence for the short-term effectiveness of our inpatient treatment concept. We recommend using DSM-5 based remission criteria to evaluate the treatment outcome to improve the comparability of studies.

Pharmacological treatment of acute-phase anorexia nervosa: Evidence from randomized controlled trials

BACKGROUND

Anorexia nervosa (AN) is the psychiatric disorder with the highest mortality rate, with a standard mortality ratio of 5.86. Despite the large use of psychotropic drugs in the clinical setting, Food and Drug Administration has not approved any psychoactive treatment for AN.

AIMS

The aim of this study was to perform an updated systematic review and meta-analysis of published randomized controlled trials (RCTs) investigating psychopharmacological treatment in acute-phase AN.

METHODS

The present paper follows the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. An extensive literature search was performed. All RCTs enrolling patients with acute-phase AN, comparing at least one psychotropic drug with another drug, placebo, treatment-as-usual or no treatment were included. The main outcome was the effect of psychoactive drugs on body mass index (BMI); data on psychopathological outcomes were also collected when available.

RESULTS

A total of 19 RCTs met all specified criteria. Of these, 11 were excluded from quantitative analyses. Of the eight studies included in the meta-analyses, five reported data on BMI, showing no significant difference between olanzapine and placebo for weight recovery. No significant result was found for AN psychopathology, depressive and anxious symptoms for any of the molecules studied.

CONCLUSIONS

RCTs published in this field display methodological biases, low sample sizes and short follow-up periods. Further research efforts are needed in this field as no evidence has been demonstrated for the use of any psychotropic drug in acute-phase AN neither for weight recovery, nor for comorbid psychiatric symptoms.

A Meta-Analysis of Dropout and Metabolic Effects of Antipsychotics in Anorexia Nervosa

BACKGROUND

Second-generation antipsychotics are often used off-label in the treatment of anorexia nervosa (AN) across the clinical spectrum. Patients with anorexia nervosa often cite concerns about metabolic effects, such as weight gain, as reasons for their reluctance to start or continue second-generation antipsychotics. Improving our understanding of the metabolic effect patients experience and reasons underlying their disinclination will enable us to build rapport and guide our clinical decisions. We therefore aimed to conduct a comprehensive review of dropouts, metabolic effects, and patient-reported outcomes associated with second-generation antipsychotic in people with AN.

METHOD

EMBASE, Medline, and PsycINFO were searched for all relevant studies published until 2019, and retrieved studies were assessed for eligibility as per predefined inclusion criteria. A random-effects meta-analysis was conducted to assess overall dropout rates.

RESULTS

Of 983 citations retrieved, 21 studies met the inclusion criteria for the systematic review and 10 studies had appropriate data for meta-analysis. Using the random effects model, the pooled dropout rate in the intervention arm (95% confidence interval) from psychopharmacological trials was 28% (19 to 38%) in people with AN. Personal reasons or factors associated with study were commonest reason for dropout, not adverse events or metabolic effects as hypothesized.

CONCLUSION

Compared to personal reasons, drug-related factors such as side effects seem to play a lesser role for the discontinuation of antipsychotic treatment under trial conditions. This suggests an urgent need to consider and fully examine potential individual and patient-related factors that influence dropout rates in psychopharmacological trials and treatment compliance in clinical settings.

Evaluation of the Effectiveness and Safety of Olanzapine as an Adjunctive Treatment for Anorexia Nervosa in Adolescents: An Open-Label Trial

OBJECTIVES

To evaluate the effectiveness and safety of adjunctive olanzapine treatment for low weight adolescents with anorexia nervosa (AN).

METHODS

A non-randomized open-label trial was conducted between 2010 and 2014. Participants received standard treatment and were invited to take olanzapine at study enrollment. Participants could accept, continue, or discontinue olanzapine as treatment progressed. Weight and psychological outcomes were monitored.

RESULTS

Of 239 adolescents assessed, 65 met inclusion criteria, 38 enrolled in the study, and 32 were retained for analysis. Twenty-two participants took olanzapine (medication group) and ten participants did not (comparison group). Participants in the medication group demonstrated a higher rate of weight gain compared to those who did not receive olanzapine (p = .012). No serious adverse events were noted, although seven participants (31.8%) discontinued olanzapine due to a side effect.

CONCLUSION

Preliminary results suggest that olanzapine may help facilitate weight gain in adolescents with AN. The importance of medical monitoring over the course of treatment is discussed. Evaluation of the Efficacy and Safety of Olanzapine for Anorexia Nervosa in Children and Adolescents; http://clinicaltrials.gov; NCT01184443.

The Role of Olanzapine in the Treatment of Anorexia Nervosa

Objective:

To evaluate the role of olanzapine in the treatment of anorexia nervosa.

Data Sources:

Literature was obtained through searches of MEDLINE (1966–December 2006), EMBASE (1980–4th Quarter 2006), and PsycINFO (1985–December 2006) and a bibliographic review of published articles. Key terms used in the searches included anorexia nervosa, antipsychotics, eating disorders, olanzapine, and Zyprexa.

Study Selection And Data Extraction:

All English language articles that were identified from the search were evaluated. All primary literature was included in the review.

Data Synthesis:

In several case reports and most clinical trials, patients with anorexia nervosa successfully gained weight while being treated with olanzapine. Moreover, many patients treated with olanzapine achieved a healthy body weight. Case reports and trials identified additional benefits of olanzapine, including reduction in delusional thinking; improvement in body image, sleep, depressive symptoms, adherence to treatment, and eating-disorder symptoms; and decreased agitation and premeal anxiety.

Conclusions:

Preliminary evidence supports the use of olanzapine for treatment of anorexia nervosa by demonstrating that olanzapine 2.5–15 mg daily promotes weight gain and has positive effects on associated psychological symptoms. Limitations of the reported data include small sample size, low completion rate in clinical trials, and open-label trial design. Although olanzapine appears to have a potential role in the treatment of anorexia nervosa that has been unresponsive to other therapy, randomized, placebo-controlled studies with larger sample sizes are necessary to establish its role in therapy.

The Role of Psychotropic Medications in the Management of Anorexia Nervosa: Rationale, Evidence and Future Prospects

Anorexia nervosa (AN) is a severe psychiatric disorder without approved medication intervention. Every class of psychoactive medication has been tried to improve treatment outcome; however, randomized controlled trials have been ambiguous at best and across studies have not shown robust improvements in weight gain and recovery. Here we review the available literature on pharmacological interventions since AN came to greater public recognition in the 1960s, including a critical review of why those trials may not have been successful. We further provide a neurobiological background for the disorder and discuss how cognition, learning, and emotion-regulating circuits could become treatment targets in the future. Making every effort to develop effective pharmacological treatment options for AN is imperative as it continues to be a complex psychiatric disorder with high disease burden and mortality.

Psychopharmacological options for adult patients with anorexia nervosa

The aim of this review was to summarize evidence from research on psychopharmacological options for adult patients with anorexia nervosa (AN). Database searches of MEDLINE and PsycINFO (from January 1966 to January 2014) were performed, and original articles published as full papers, brief reports, case reports, or case series were included. Forty-one papers were screened in detail, and salient characteristics of pharmacological options for AN were summarized for drug classes. The body of evidence for the efficacy of pharmacotherapy in AN was unsatisfactory, the quality of observations was questionable (eg, the majority were not blinded), and sample size was often small. More trials are needed, while considering that nonresponse and nonremission are typical of patients with AN.

Interacting Neural Processes of Feeding, Hyperactivity, Stress, Reward, and the Utility of the Activity-Based Anorexia Model of Anorexia Nervosa

Anorexia nervosa (AN) is a psychiatric illness with minimal effective treatments and a very high rate of mortality. Understanding the neurobiological underpinnings of the disease is imperative for improving outcomes and can be aided by the study of animal models. The activity-based anorexia rodent model (ABA) is the current best parallel for the study of AN. This review describes the basic neurobiology of feeding and hyperactivity seen in both ABA and AN, and compiles the research on the role that stress-response and reward pathways play in modulating the homeostatic drive to eat and to expend energy, which become dysfunctional in ABA and AN.

[Affective disorders and eating disorders]

Epidemiologic studies show a frequent co-occurence of affective and eating disorders. The incidence of one disorder in patients suffering from the other disorder is well over the incidence in the general population. Several causes could explain this increased comorbidity. First, the iatrogenic origin is detailed. Indeed, psychotropic drugs, and particularly mood stabilizers, often lead to modification in eating behaviors, generally inducing weight gain. These drugs can increase desire for food, reduce baseline metabolism or decrease motor activity. Also, affective and eating disorders share several characteristics in semiology. These similarities can not only obscure the differential diagnosis but may also attest of conjoint pathophysiological bases in the two conditions. However, genetic and biological findings so far are too sparse to corroborate this last hypothesis. Nonetheless, it is noteworthy that comorbidity of affective and eating disorders worsens patients'prognosis and is associated with more severe forms of affective disorders characterized by an earlier age of onset in the disease, higher number of mood episodes and a higher suicidality. Lastly, psychotropic drugs used in affective disorders (lithium, antiepileptic mood stabilizers, atypical antipsychotics, antidepressants) are reviewed in order to weigh their efficacy in eating disorders. This could help establish the best therapeutic option when confronted to comorbidity.

Eating disorders and psychosis: Seven hypotheses

Psychotic disorders and eating disorders sometimes occur in the same person, and sometimes, but not always, at the same time. This can cause diagnostic confusion and uncertainty about treatment. This paper examines seven ways in which symptoms of both conditions can co-exist. The literature on this topic consists to a large extent of case reports, so that firm conclusions cannot be drawn from their examination. There is no consistent sequence in the co-occurrence of the two conditions-eating disorders sometimes precede, and sometimes follow the onset of psychosis. The advent of the psychosis, and sometimes the treatment of the psychosis can cure the eating disorder, but it can sometimes aggravate it. Psychosis is not necessarily a mark of severity in the course of an eating disorder, and food refusal can occur independent of severity in psychotic illness, but it can be a cause of death. There is some genetic association and some overlap of physiologic, cognitive and brain structure deficits in the two types of disorder. The connection between the two, however, remains speculative. The area of comorbidity and overlapping symptoms in psychiatry requires more research. Clinical recommendations include attention to the different individual ways in which these two disparate conditions often overlap.

Nothing tastes as good as skinny feels: the neurobiology of anorexia nervosa

Individuals with anorexia nervosa (AN) engage in relentless restrictive eating and often become severely emaciated. Because there are no proven treatments, AN has high rates of relapse, chronicity, and death. Those with AN tend to have childhood temperament and personality traits, such as anxiety, obsessions, and perfectionism, which may reflect neurobiological risk factors for developing AN. Restricted eating may be a means of reducing negative mood caused by skewed interactions between serotonin aversive or inhibitory and dopamine reward systems. Brain imaging studies suggest that altered eating is a consequence of dysregulated reward and/or awareness of homeostatic needs, perhaps related to enhanced executive ability to inhibit incentive motivational drives. An understanding of the neurobiology of this disorder is likely to be important for developing more effective treatments.

Differential weight restoration on olanzapine versus fluoxetine in identical twins with anorexia nervosa

OBJECTIVE

No studies have compared the response to selective serotonin reuptake inhibitors and atypical antipsychotics in anorexia nervosa. This case study examines such a comparison.

METHOD

This report describes a case of 12-year-old identical twins with anorexia nervosa, one of whom was treated with olanzapine and the other with fluoxetine, while undergoing family therapy.

RESULTS

Twin A treated with fluoxetine went from 75 to 84.4% ideal body weight, while Twin B treated with olanzapine went from 72 to 99.9% ideal body weight over the course of 9 months.

DISCUSSION

This case supports the need for adequately powered, controlled clinical trials to test the efficacy of olanzapine in adolescents presenting with anorexia nervosa.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of eating disorders

OBJECTIVES

The treatment of eating disorders is a complex process that relies not only on the use of psychotropic drugs but should include also nutritional counselling, psychotherapy and the treatment of the medical complications, where they are present. In this review recommendations for the pharmacological treatment of eating disorders (anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED)) are presented, based on the available literature.

METHODS

The guidelines for the pharmacological treatment of eating disorders are based on studies published between 1977 and 2010. A search of the literature included: anorexia nervosa bulimia nervosa, eating disorder and binge eating disorder. Many compounds have been studied in the therapy of eating disorders (AN: antidepressants (TCA, SSRIs), antipsychotics, antihistaminics, prokinetic agents, zinc, Lithium, naltrexone, human growth hormone, cannabis, clonidine and tube feeding; BN: antidepressants (TCA, SSRIs, RIMA, NRI, other AD), antiepileptics, odansetron, d-fenfluramine Lithium, naltrexone, methylphenidate and light therapy; BED: antidepressants (TCA, SSRIs, SNRIs, NRI), antiepileptics, baclofen, orlistat, d-fenfluramine, naltrexone).

RESULTS

In AN 20 randomized controlled trials (RCT) could be identified. For zinc supplementation there is a grade B evidence for AN. For olanzapine there is a category grade B evidence for weight gain. For the other atypical antipsychotics there is grade C evidence. In BN 36 RCT could be identified. For tricyclic antidepressants a grade A evidence exists with a moderate-risk-benefit ratio. For fluoxetine a category grade A evidence exists with a good risk-benefit ratio. For topiramate a grade 2 recommendation can be made. In BED 26 RCT could be identified. For the SSRI sertraline and the antiepileptic topiramate a grade A evidence exists, with different recommendation grades.

CONCLUSIONS

Additional research is needed for the improvement of the treatment of eating disorders. Especially for anorexia nervosa there is a need for further pharmacological treatment strategies.

Aripiprazole in anorexia nervosa and low-weight bulimia nervosa: case reports

OBJECTIVE

There has been much interest in the use of atypical antipsychotics in anorexia nervosa (AN). However, newer, more weight-neutral medications have not been studied in AN, and there are no reports of the use of antipsychotics in bulimia nervosa (BN).

METHOD

We report on the treatment of eight patients (five with AN and three with BN) with aripiprazole for time periods of four months to more than three years.

RESULTS

All individuals had reduced distress around eating, fewer obsessional thoughts about food, weight and body image, significant lessening of eating-disordered behaviors, and gradual weight restoration where appropriate. Depression, generalized anxiety, and cognitive flexibility improved as well.

DISCUSSION

In summary, these findings support the need to perform controlled trials of aripiprazole in AN and BN.

Auditory hallucinations in anorexia nervosa

The paper describes two case studies of patients with anorexia nervosa who suffer from auditory hallucinations as the only psychotic symptom. A review of the literature regarding clinical cases of anorexic patients with hallucinations is discussed. Hallucinations in anorexic patients are conceptualized according to different theoretical models which point to a dimensional view of eating disorders.

Management of anorexia and bulimia nervosa: An evidence-based review

Anorexia nervosa and bulimia nervosa are primarily psychiatric disorders characterized by severe disturbances of eating behavior. Eating disorders are most prevalent in the Western culture where food is in abundance and female attractiveness is equated with thinness. Eating disorders are rare in countries like India. Despite a plethora of management options available to the mental health professionals, no major breakthrough has been achieved in recent years. Nutritional rehabilitation along with some form of re educative psychotherapy remains the mainstay of management of anorexia nervosa. In bulimia nervosa, both fluoxetine and cognitive behavior therapy have been found to be effective. Although the above-mentioned management options have been in use for decades, the active ingredient is still to be ascertained.

Low-dose olanzapine monotherapy in girls with anorexia nervosa, restricting subtype: focus on hyperactivity

OBJECTIVE

The aim of this study was to evaluate the efficacy of olanzapine in girls with anorexia nervosa, restricting subtype (ANr).

METHODS

Thirteen patients (mean age 13.7 +/- 2.3 years, age range 9.6-16.3 years) enrolled in a multimodal treatment for ANr were evaluated with standardized measures at baseline and after 1 and 6 months after starting low-dose olanzapine monotherapy (mean dose 4.13 mg/day).

RESULTS

A significant improvement was evident on weight (body mass index, BMI), global functioning (Children's Global Assessment Scale, CGAS), eating attitudes (Eating Attitudes Test-26, EAT-26), anxious-depressive symptoms (Child Behavior Checklist, CBCL) and hyperactivity (Structured Inventory for Anorexic and Bulimic Syndromes, SIAB). At the end of the 6-month follow up, 7 patients were responders according to an improvement of at least 50% in the EAT-26 results. The only measure that improved significantly in responders, but not in nonresponders, was hyperactivity (SIAB). Clinical improvement, in terms of both body mass index (BMI) recovery and global functioning, paralleled the improvement of hyperactivity, was evident at the end of the first month of treatment, and further increased in the following 5 months, with minimal side effects.

CONCLUSIONS

Low-dose olanzapine monotherapy may be useful as adjunctive treatment of youths with ANr. It is suggested that efficacy may be mediated by a decrease of hyperactivity.

Atypical antipsychotics and anorexia nervosa: a review

BACKGROUND

There is currently mixed opinion regarding the value of using atypical antipsychotics to treat anorexia nervosa (AN).

AIMS

To evaluate the literature on the use of atypical antipsychotics in AN.

METHOD

A review of all studies and clinical guidelines published before September 2009 involving use of an atypical antipsychotic in patients with AN. Analysis is by narrative synthesis.

RESULTS

Forty-three publications or study protocols were found, including four randomized-controlled trials, five open-label trials and 26 case reports. The most studied drugs were olanzapine, quetiapine and risperidone. Atypical antipsychotics appear safe and there is some evidence of positive effects on depression, anxiety and core eating disordered psychopathology in patients with anorexia nervosa. Currently there is insufficient evidence to confirm atypical antipsychotics enhance weight gain in this setting.

CONCLUSIONS

Further high quality evidence is needed in this area in order to provide practical guidance to clinicians. However, the main challenge is to persuade adequate numbers of AN patients to participate in research trials.

Dopamine antagonism inhibits anorectic behavior in an animal model for anorexia nervosa

Excessive physical activity is commonly described as symptom of Anorexia Nervosa (AN). Activity-based anorexia (ABA) is considered an animal model for AN. The ABA model mimics severe body weight loss and increased physical activity. Suppression of hyperactivity by olanzapine in anorectic patients as well as in ABA rats suggested a role of dopamine and/or serotonin in this trait. Here, we investigated the effect of a non-selective dopamine antagonist in the ABA model. A dose-response curve of chronic treatment with the non-selective dopaminergic antagonist cis-flupenthixol was determined in the ABA model. Treatment reduced activity levels in both ad libitum fed and food-restricted rats. Treated ABA rats reduced body weight loss and increased food intake. These data support a role for dopamine in anorexia associated hyperactivity. Interestingly, in contrast to leptin treatment, food-anticipatory activity still persists in treated ABA rats.

What potential role is there for medication treatment in anorexia nervosa?

OBJECTIVE

To review selected issues regarding the development of drug treatments for anorexia nervosa (AN).

METHOD

The existing pharmacotherapy literature for AN is reviewed, and the theoretical and practical considerations are discussed.

RESULTS

A very wide variety of drugs have been examined in AN, generally with negative results. There are a number of potential reasons for this finding, including compliance, nutritional deficits, selection of the wrong targets or the wrong outcome measures, use of monotherapy, lack of animal models, or factors intrinsic to AN.

CONCLUSION

Pharmacotherapy provides little benefit in the treatment of AN at present. Several strategies might lead to the identification of more effective agents, including new measurement strategies, identification of novel pharmacologic targets, and consideration of a clinical trials network.

Atypical antipsychotics in severe anorexia nervosa in children and adolescents--review and case reports

OBJECTIVE

To review the literature on the use of atypical antipsychotics in anorexia nervosa of children and adolescents and to present three case reports on quetiapine treatment of this subgroup.

METHOD

Review of the literature and case report.

RESULTS

Several case reports and two small open-label trials, mainly in adults, observed beneficial effects of olanzapine on anorexic psychopathology. Only 16 case reports have been published on children and adolescents. Because of its lower propensity to induce weight gain quetiapine might be favourable with regard to patients' compliance. Our case reports revealed positive psychopathological effects and good tolerability of quetiapine in minors with severe anorexia nervosa. Careful titration and intense drug monitoring are recommended.

DISCUSSION

In a small subset of patients with severe, treatment- resistant anorexia nervosa, extreme weight phobia, delusional body image disturbances or severe hyperactivity might be considered as indications for atypical antipsychotics. However, controlled studies are needed.

Psychopathological and nutritional correlates of plasma homovanillic acid in adolescents with anorexia nervosa

Dopaminergic abnormalities have been described in anorexia nervosa but studies about plasma level of homovanillic acid (pHVA) have yielded conflicting results probably due to the small number and the heterogeneity of patients. Plasma HVA, nutritional and hormonal parameters and several scales - the Eating Attitudes Test (EAT), the Beck Depression Inventory (BDI), the Leyton Obsessional Inventory-child version (LOI-C) and the State and Trait Anxiety Inventory (STAI) - were assessed in 44 adolescent anorexia nervosa patients (mean age 14.7 years, SD 1.7) consecutively admitted to an Eating Disorder Unit. They were evaluated at admission, at discharge and, in 34 cases, after 9 months of follow-up. pHVA was also assessed in 16 control adolescents. Patients had significantly higher pHVA than controls (p = .002). About 31% of patients had a very high level of pHVA, a significantly higher (p = .006) mean score in the BDI and a non significantly higher mean score in the EAT. After weight recovery some laboratory parameters improved as well as the EAT (p = .019), the BDI (p = 001) and the Interference score of the LOI-C (p = .004). Moreover, pHVA decreased significantly (p=.036). At follow-up, patients with normal weight had lower (p = .037) pHVA than patients with low weight. The conclusion would be that there is a dopaminergic dysfunction in anorexic patients, specially in a subgroup with high depressive and anorexic symptomatology. With weight recovery and psychopathological improvement, pHVA tends to normalization.

Tolerability and efficacy of aripiprazole in a case of psychotic anorexia nervosa comorbid with epilepsy and chronic renal failure

INTRODUCTION

The aim of this case report was to examine the therapeutic benefit and tolerability of aripiprazole for psychotic symptoms in a case of anorexia nervosa comorbid with generalized epilepsy, chronic renal failure and Raynaud syndrome.

CASE REPORT

The patient had a chronic anorexia nervosa with psychotic symptoms, already treated with risperidone without efficacy, mainly because it was underdosed due to side-effects. She refused to take olanzapine (fear of weight gain) but accepted a treatment with aripiprazole. Aripiprazole 30 mg/day was associated with considerable improvement of SANS and SAPS (scale for the assessment of negative and positive symptoms) scores on hallucinations, delusions, aggressivity, abulia and asociality. Weight remained stable and no side-effects were reported.

DISCUSSION

These findings lend support to the possibility that aripiprazole may be useful and well tolerated in psychotic anorexia and in cases of comorbidity with epilepsy and/or renal failure. These data are preliminary and need to be confirmed in further controlled research.

Olanzapine therapy in anorexia nervosa: psychobiological effects

Dopamine impairments occur in anorexia nervosa. The aim of this study was to see whether treatment with the atypical dopamine antagonist antipsychotic olanzapine improves the disorder. Thirty anorexics, 18 restricted and 12 bingeing-purging, underwent a 3-month course of cognitive behavioral therapy, plus at random and double-blinded oral olanzapine (2.5 mg for 1 month, 5 mg for 2 months) in half and oral placebo in the other half of them. BMI, psychopathological aspects (eating disorder inventory, Hamilton Rating Scale, Buss-Durkee Rating Scale, Yale Brown Cornell for Eating Disorders Rating Scale, temperament-character inventory), and homovanillic acid blood concentrations for dopamine secretion, were monitored at baseline and then monthly during the trial. At the end of the trial BMI, total eating disorder inventory, total Yale Brown Cornell for Eating Disorders Rating Scale, Buss-Durkee Rating Scale, Hamilton Rating Scale scores and in olanzapine-treated patients the subitems of eating disorder inventory ineffectiveness and maturity fear, of Buss-Durkee Rating Scale direct aggressiveness, of temperament-characteristic inventory persistence had improved significantly. When stratified for anorexia nervosa subtype, BMI changes were significant among anorexia nervosa bingeing-purging patient, 'depression' (Hamilton Rating Scale) and 'direct aggressiveness' (Buss-Durkee Rating Scale) among anorexia nervosa bingeing-purging patients, 'persistence' (temprerament-characteristic inventory), among anorexics restricted patients, with a trend toward significance for obsessivity-compulsivity (Yale Brown Cornell for Eating Disorders Rating Scale). homovanilic acid blood levels increased significantly in the cognitive behavioral therapy+olanzapine group. No correlations were observed between homovanilic acid concentrations and psychopathological parameters. The pharmacological treatment can significantly improve specific aspects of anorexia nervosa.

Olanzapine-induced weight gain in anorexia nervosa: involvement of leptin and ghrelin secretion?

BACKGROUND

Olanzapine (OLA) administration has been reported to induce weight gain in experimental animals and humans, through not yet fully defined mechanisms of action. Aim of this study was to determine whether in patients with Anorexia Nervosa (AN) OLA induces weight gain through the modulation of the hunger-satiety regulatory peptides leptin and ghrelin.

METHODS

Twenty anorexic probands received a 3 months course of cognitive-behavioral psychotherapy and programmed nutritional rehabilitation, combined with OLA PO (2.5 mg for 1 month and 5 mg for 2 months) in ten patients and with placebo PO (PL) in the other 10. Weight, measured as body mass index (BMI), leptin and ghrelin plasma values were monitored before starting the therapy and then monthly for 3 months. Plasma leptin was measured by ELISA, and plasma ghrelin by radioimmunoassay.

RESULTS

BMI increased significantly but not differently in both treatment groups. Leptin and ghrelin secretion did not change during the course of the treatments. No correlations were observed between BMI values and leptin and ghrelin levels.

CONCLUSIONS

Our data suggest that the weight gain observed in our OLA-treated patients was not linked to drug administration. Moreover, leptin and ghrelin secretions were not responsible for BMI changes.

Prescription de l’olanzapine chez l’enfant et l’adolescent

INTRODUCTION

A review of the literature from 1996-2004 on the indications and adverse reactions concerning the use of olanzapine, a second generation antipsychotic agent, in children and adolescents with psychiatric illness is made in this article. Studies lasted for 2 to 3 months and a few had a follow up period up to a year. Olanzapine, dosed from 2.5 to 20 mg/day, is shown to be a useful drug in the treatment of child and adolescent onset schizophrenia, bipolar disorder, anorexia nervosa with delusions, pervasive developmental disorder, tic disorders, and aggression. OPEN AND DOUBLE-BLIND STUDIES: In 4 open labeled studies (26, 34, 39, 43) and 2 case reports (25), 53 patients, aged from 6-18 years old, afflicted by child onset schizophrenia, were treated with olanzapine for 1 1/2 weeks to one year; 19 had treatment resistant childhood schizophrenia and 34 a first episode. In the first group 13/19 showed improvement whereas, in the second group 27/34 were considered responders. Four patients in the first group who had responded to clozapine (stopped because of adverse events) did less well on olanzapine. In 5 studies, 4 open labeled (15, 20, 44) and 1 double blind (27), 59 adolescent onset schizophrenic patients were treated by olanzapine from 8 to 26 weeks; 50/59 patients were considered responders. In the open label study (20) comparing 43 adolescents treated by olanzapine (19 patients), risperidone (17 patients), or haloperidol (7 patients), improvement was significant in the three groups after 4 weeks of treatment and continued after 8 weeks. It is most interesting to mention that 2 months after the end of the study 71% (12/17) of the olanzapine group that had completed the study, 10/15 (67%) of the risperidone group, and 43% (3/7) of the haloperidol group had continued their treatment. Dropouts were for inefficacy and non-compliance in the olanzapine and risperidone groups whereas they were also for adverse events in the haloperidol group (2/4). A final double blind study of 263 adult and adolescent schizophrenic patients (latter are not separated from the former) confirmed the superiority of olanzapine compared to haloperidol and its use for a long period: 67% of the olanzapine and 54% of the haloperidol patients completed the 12-week study.

CASE-REPORTS

12 case reports of children and adolescents diagnosed with acute mania (8, 25, 46, 47) and 23 in an open labeled study (16) were treated by olanzapine; 26/35 were considered to respond well. Some of the patients were on mood stabilizers before adjunction of olanzapine, others on olanzapine monotherapy; 10 case reports of patients with anorexia nervosa associated with psychotic symptomatology, aged from 10-17 years old, relate the use of olanzapine as adjuvant treatment. Improvement was spectacular in these patients who not only gained considerable weight, but were also more compliant to the therapeutic program and their obsessions, delusions, agitation and anxiety became less intense. In this form of anorexia nervosa, olanzapine appears to have an interesting therapeutic role and, in particular, its most important adverse effect, weight gain, became a therapeutic goal. In 2 preliminary studies (24, 30) 31 children and adolescents diagnosed with pervasive developmental disorder were treated by olanzapine from 6 to 13 weeks; 18/25 had good or moderate symptomatic improvement: they were less irritable and hyperactive, and their speech less excessive. In 17 case reports of children and adolescents with aggression (42, 45), associated with tics in 10 patients (49), treatment with olanzapine from 2 weeks to 10 months lowered the presenting symptoms, enhanced the cooperation, and improved the mood of the patients. Only one patient's treatment was changed for inefficacy.

DISCUSSION

No matter what the disorder treated, when olanzapine was compared to haloperidol and risperidone, it proved to be as effective as risperidone, and as or more effective than haloperidol; but when compared to clozapine, it was less effective. The most prominent adverse reaction was excessive weight gain, even more so than in adult patients treated with olanzapine. Also weight gain was greater in children and adolescents treated by olanzapine than those treated by risperidone or haloperidol. Though few treatments had to be interrupted because of this side effect, child and adolescent psychiatrists are wary of the long-term disease related to obesity and glucose dysregulation. All should be done to under-stand the process of weight gain better and to prevent or stall excessive caloric intake, encourage activity, and eventually treat by corrector drugs. Secondly, sedation may bother up to 50% of patients even at the end of the study periods, as many as those treated by haloperidol and more than those treated by risperidone. Extrapyramidal symptoms were mild or moderate compared to those that appear with haloperidol, but may be more frequent than in adult patients. Liver enzymes and blood sugar may be slightly elevated. Prolactemia may be elevated but less so with risperidone and haloperidol.

CONCLUSION

All the authors emphasized the unfortunate lack of randomized double blind studies for the use of olanzapine in this age group.

Eating disorders in the 21st century: identification, management, and prevention in obstetrics and gynecology

Eating disorders are extremely common and carry a high degree of medical and psychiatric morbidity. These disorders are challenging to treat because many patients deny their symptoms, have poor motivation to change, and can become frustrating to the clinician. Case identification based upon suggested screening questions and ongoing management of medical consequences are important roles for the obstetrician/gynecologist involved in the care of these patients. This chapter discusses the benefits and limitations of contemporary treatment, special populations at risk (e.g. athletes, diabetics), and screening guidelines for office practice. Signs, symptoms, laboratory abnormalities, and the perils of associated psychiatric illness are briefly reviewed. Patients do respond to a comprehensive, integrated treatment plan that includes nutritional stabilization, psychotherapy, and pharmacotherapy. Collaboration between all professionals involved in the patient's care is essential for state-of-the-art care. Those patients who become pregnant or wish to become pregnant pose certain additional treatment considerations. Ongoing and future research aimed at understanding how eating disorders develop - and may be prevented by early identification and education - will result in enhanced knowledge of these life-threatening and often chronic illnesses in the 21st century.

Quetiapine in anorexia nervosa patients: an open label outpatient pilot study

OBJECTIVES

The main objective of the study was to determine whether quetiapine was effective in reducing scores on the positive and negative syndrome scale (PANSS) in anorexia nervosa (AN) patients. Secondary objectives included determining whether quetiapine was effective in reducing symptoms of anxiety and depression. In addition, the effect on weight was determined.

METHOD

In an open label design, 19 patients with AN but without schizophrenia or schizoaffective disorder were given 150-300 mg quetiapine daily over a 10 week period. Results were analyzed using last observation carried forward (LOCF).

RESULTS

Fourteen patients completed the study and all but one of the 5 patients who dropped out returned for an early termination visit. Scores on the total, general psychopathology, and depression scales of the PANSS declined significantly (p = .024, .010, .0005, respectively) at LOCF. There were improvements in several measures of anxiety, depression, and obsessive compulsive symptoms. Mean weight gain was modest at 1.6 lbs (0.73 kg). Adverse events were generally mild and no patients discontinued due to adverse events

CONCLUSION

Quetiapine was well-tolerated and patients had significant improvements in several subscales of the PANSS as well as decreases in measures of anxiety and depression.

Comorbidity of eating disorders with bipolar disorder and treatment implications

OBJECTIVES

To review the scientific evidence examining the comorbidity among eating disorders and bipolar disorder (BD).

METHODS

We reviewed all published English-language studies addressing the comorbidity of anorexia nervosa, bulimia, bulimia nervosa, and binge eating disorder in patients with BD and studies of comorbidity of BD in patients with eating disorders. In addition, we discuss the pharmacologic treatment implications from reviewed studies of agents used in BD and eating disorders.

RESULTS

Community and clinical population studies of the lifetime prevalence rates of eating disorders in patients with BD, and of BD in patients with eating disorders, particularly when subthreshold and spectrum manifestations of these disorders are included, indicate high rates of comorbidity among these illnesses.

CONCLUSIONS

Pharmacologic treatment approaches to patients with BD and a co-occurring eating disorder require examination of the possible adverse effects of the treatment of each syndrome on the other and attempts to manage both syndromes with agents that might be beneficial to both.

Combined treatment of olanzapine and mirtazapine in anorexia nervosa associated with major depression

Several studies have shown that olanzapine is effective in weight restoration and maintenance for patients with anorexia nervosa (AN). However, major depression is a very common comorbid psychiatric disorder associated with AN. Additional antidepressant therapy may be required for treating anorexic patients with major depression. The authors present a case of AN associated with major depression, who responded well to the combination treatment of olanzapine and mirtazapine. A 27-year-old Taiwanese woman was admitted because of severe weight loss, poor nutrition, amenorrhea, major depression, and starvation complications including hematological dyscrasis, electrolytes and endocrine imbalance, and sinus bradycardia. In additional to nutritional and medical treatments, the patient was given olanzapine 10 mg/day and mirtazapine 30 mg/day. She took the combined medications for six months. Meanwhile she received cognitive behavior therapy and family therapy. With these treatments, the patient's depression was in remission, her body weight was increased from 24 to 38 kg, and her body mass index was increased from 9.8 to 15.5. Our case suggests that the combined treatment of olanzapine and mirtazapine can be used in the treatment of AN associated with major depression.

Atypical uses of atypical antipsychotics

Atypical antipsychotic drugs are primarily indicated for the treatment of psychotic disorders such as schizophrenia and schizoaffective disorder. Recently, they have also been used for mood stabilization. This article reviews other, potentially therapeutically useful indications for these medications. In most cases, the evidence supporting these new uses is limited but provocative, and involves only case reports. It has not yet been determined whether the usefulness of atypical antipsychotics for nonpsychotic disorders outweighs their potential to cause serious side effects.

Psychotropic medication use at a private eating disorders treatment facility: A retrospective chart review and descriptive data analysis

BACKGROUND

The extent of psychotropic medication use in patients with eating disorders worldwide is unknown.

OBJECTIVES

THE PURPOSES OF THIS STUDY WERE TO: (1) describe the extent and pattern of psychotropic medication use at a private treatment facility for patients with eating disorders and (2) describe patient characteristics and treatment outcomes at the facility.

METHODS

This retrospective chart review included data from a private treatment facility (inpatient or outpatient) for patients with eating disorders in the greater Los Angeles area. Data from all patients of any age who attended the facility between January 1, 2004, and January 1, 2005, and who met the criteria for anorexia nervosa (AN), bulimia nervosa (BN), or eating disorder not otherwise specified (ED NOS) defined in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision were included. Two investigators used a consistent chart-review method for recording clinical status, including treatment-related adverse effects and discharge status (improved, no change, or decompensated from admission). Improved was defined as meeting 1 or more of the following criteria: achieved ideal body weight, stabilized mood, decreased eating disorder symptoms (binge-purge, restrictive, or ritualistic behavior), eating disorder remission, or decreased suicidal ideation plus another improvement in this list.

RESULTS

Data from 60 patients were included (31 with AN, 28 with 13N, and I with ED NOS). Ages ranged from 12 to 47 years, and the mean duration of treatment was 35 days. Fifty-eight (96.7%) patients received a psychotropic agent; 35 (58.3%) patients were prescribed 2 or more agents concomitantly. Selective serotonin reuptake inhibitors (SSRls) were the most commonly prescribed class of psychotropic medication (86.7%), followed by antipsychotics (38.3%). Fluoxetine, escitalopram, and aripiprazole were the most commonly prescribed agents (41.7%, 28.3%, and 23.3%, respectively). A total of 63.3% of patients had a comorbid diagnosis of major depressive disorder, with 96.7% of these patients prescribed an antidepressant. At discharge, 51.6% of the inpatients and 37.9% of the outpatients had improved (AN, 52.6% and 33.3%, respectively; BN, 54.5% and 41.2%, respectively). Of the patients prescribed an SSRI, 40.4% had improved. In the inpatient setting, 35.5% of patients receiving an antipsychotic had improved, versus 6.9% in the outpatient setting.

CONCLUSIONS

The results of this retrospective chart review and descriptive analysis of data from patients at a private eating disorders treatment facility in the United States suggest that psychotropics, particularly antidepressants and antipsychotics, were highly utilized, largely to treat comorbid symptoms. Fluoxetine, escitalopram, and aripiprazole were the most commonly prescribed agents. We observed that psychotropic medication selection was based on patient comorbidities and symptom expression and severity.

Olanzapine reduces physical activity in rats exposed to activity-based anorexia: possible implications for treatment of anorexia nervosa?

BACKGROUND

Anorexia nervosa (AN) patients often show extreme hypophagia and excessive physical activity. Activity-based anorexia (ABA) is considered an animal model of AN and mimics food restriction and hyperactivity in rats. This study investigated whether treatment with olanzapine (Zyprexa) reduces the development of ABA in rats. The effect of olanzapine treatment in AN patients was also evaluated in a small open-label study.

METHODS

Rats were chronically (1 week) infused with olanzapine (7.5 mg/kg) and exposed to the ABA model or ad libitum feeding. Hyperactive AN patients were followed for up to 3 months of olanzapine treatment (5 mg/kg).

RESULTS

Olanzapine treatment reduced development of ABA in rats by reducing running wheel activity, starvation-induced hypothermia and activation of the hypothalamus-pituitary-adrenal axis. Olanzapine treatment reduced activity levels of AN patients compared with untreated AN patients, without affecting body weight and plasma leptin levels.

CONCLUSIONS

Olanzapine treatment reduced wheel running and thereby diminished development of ABA in rats. Olanzapine treatment also reduced physical activity in hyperactive AN patients in a small open-label study. These data support the need for controlled studies investigating the putative beneficial effects of olanzapine treatment in AN patients.

MicroPET imaging in an animal model of anorexia nervosa

Anorexia nervosa is a life-threatening psychiatric disorder characterized by severe weight loss and high rates of comorbidity and mortality. The current study assessed the feasibility of using microPET imaging to study the effects of chronic food restriction in an animal model of anorexia nervosa. To establish preliminary support for this model, we hypothesized that chronic food restriction would decrease relative 2-deoxy-2-[18F]fluoro-D-glucose (18FDG) uptake in the rat, in effect modeling cerebral glucose hypometabolism reported in the clinical population of anorexia nervosa. Nine adolescent Wistar female rats received a baseline 18FDG scan. The control group received free access to food for a period of 25 days. The food restricted (FR) group received 40% of their baseline daily food intake until a 30% weight loss occurred; body weight was then maintained at 70% of baseline by adjusting daily food intake. The FR group also had free access to a running wheel for a mean period of 10.8+/-6.1 days. Both groups received a follow-up 18FDG scan. Relative 18FDG uptake was significantly increased in the cerebellum and significantly decreased in the hippocampus and striatum in the FR group compared to controls. Moreover, there was a trend towards a decrease in relative 18FDG uptake in the thalamus in the FR compared to control group. This is the first study to establish support for the use of microPET imaging in an animal model of anorexia nervosa as a means for studying the neurobiological changes that occur due to chronic food restriction.

Comorbidity of bipolar and eating disorders: distinct or related disorders with shared dysregulations?

BACKGROUND

The co-occurrence of bipolar and eating disorders, though of major clinical and public health importance, remains relatively unexamined.

METHODS

In reviewing the literature on this comorbidity, we compared bulimia, anorexia nervosa, bulimia nervosa, binge eating disorders and bipolar disorders on phenomenology, course, family history, biology, and treatment response.

RESULTS

Epidemiological studies show an association between subthreshold bipolar disorder and eating disorders in adolescents, and between hypomania and eating disorders, especially binge eating behavior, in adults. Of the clinical studies, most show that patients with bipolar disorder have elevated rates of eating disorders, and vice versa. Finally, the phenomenology, course, comorbidity, family history, and pharmacologic treatment response of these disorders show considerable overlap on all of these parameters. In particular, on phenomenologic grounds--eating dysregulation, mood dysregulation, impulsivity and compulsivity, craving for activity and/or exercise--we find many parallels between bipolar and eating disorders. Overall, the similarities between these disorders were more apparent when examined in their spectrum rather than full-blown expressions.

LIMITATIONS

Despite an extensive literature on each of these disorders, studies examining their overlap across all these parameters are relatively sparse and insufficiently systematic.

CONCLUSIONS

Nonetheless, the reviewed literature leaves little doubt that bipolar and eating disorders--particularly bulimia nervosa and bipolar II disorder--are related. Although several antidepressants and mood stabilizers have shown promise for eating disorders, their clinical use when these disorders co-exist with bipolarity is still very much of an art. We trust that this review will stimulate more rigorous research in their shared putative underlying psychobiologic mechanisms which, in turn, could lead to more rational targeted treatments.

New targets in the treatment of anorexia nervosa

The pathophysiology of anorexia nervosa (AN) is complex and involves alterations of serotonin, dopamine and histamine neurotransmitters. In addition, receptor activity is disturbed, presumably in response to the neurotransmitter changes. These alterations are reviewed in relation to symptomatology and outcome of AN. Neuropeptide and peripheral orexigenic and satiety peptide research is in its infancy but holds much promise to shed light on the pathophysiological mechanisms involved in this illness. Current drug therapies have not demonstrated the efficacy desired in the treatment of AN. Current therapies are reviewed and new drug targets are explored. Compounds that interact with serotonin, histamine and dopamine receptors may offer unique treatment opportunities. In the future, the manipulation of peptides may add to the therapeutic potential of pharmacotherapy.

Serotonergic and dopaminergic systems in anorexia nervosa: a role for atypical antipsychotics?

OBJECTIVE

To review serotonergic and dopaminergic system function in anorexia nervosa in terms of potential modulation by atypical antipsychotic medications.

METHOD

A systematic review of clinical, neurobiological and functional neuroimaging findings of serotonergic and dopaminergic system activity in anorexia nervosa was conducted via MEDLINE, PsycINFO and EMBASE psychiatry databases, with a critical review of dysregulation of these systems as therapeutic targets for atypical antipsychotics, in context of evidence regarding the utility and efficacy of these medications in this syndrome.

RESULTS

There is evidence of persistently altered serotonergic and dopaminergic function in anorexia nervosa independent to weight-recovery. Case reports, open-label and single-blinded studies, albeit sparse, suggest that atypical antipsychotics may be beneficial in the management of anorexia nervosa psychopathology beyond weight gain.

CONCLUSIONS

Double-blind placebo controlled studies of atypical antipsychotics in anorexia nervosa with well defined outcome measures are required.

The psychopharmacotherapy of anorexia nervosa: clinical, neuroendocrine and metabolic aspects

Anorexia nervosa (AN) is a complex mental disorder presenting psychiatric and physical symptoms. Literature recognizes the role of several factors in the pathogenesis of this disorder, according to the biopsychosocial model. Many mechanisms are still partly unclear. Endocrine and metabolic alterations usually occur in AN, probably having a role in its pathogenesis and in the disorder perseverance. In consideration of the multifactorial pathogenesis, a multidisciplinary approach is needed in the treatment of anorexic patients. Up-to-date psychotherapy, psychopharmacological, endocrine and nutritional treatments are considered effective in improving AN. Literature does not however provide evidence of a single validated psychopharmacotherapy for anorexic patients. It is known that psychopharmacotherapy can influence hormonal and metabolic states in some conditions, but for the moment few data are present about these effects in AN. This article aims to review the data about the psychopharmacotherapy role in AN, focusing on the endocrine and metabolic effects of anti-depressants (AD) and novel antipsychotic drugs which seem to be the most effective in AN. Scant data are however available and further research should provide more evidence about these effects and also assess whether the severity of the neuroendocrine, hormonal and metabolic impairments can predict the lack of response to the psychopharmacological treatment with AD and neuroleptics.

9th Annual Meeting of the Eating Disorders Reasearch Society

The application of modern neurobiological probes to the field of eating disorders has yielded new and exciting insights into the underlying mechanisms and causes of these devastating conditions. Findings from neuroimaging studies and genetic investigations have further confirmed and expanded our understanding of the role of the serotonin system in anorexia nervosa (AN) and bulimia nervosa. In addition, reduced regional cerebral blood flow in the temporal lobes and related brain structures have been identified in patients with AN, even after recovery. These data may hold promise for the development of more effective treatment strategies for these often chronic and refractory conditions. Results of reported treatment studies demonstrate the role and effectiveness of psychotherapy for AN and 'eating disorder not otherwise specified'; two eating disorders for which there is a paucity of empirically based treatments. Finally, more results from open studies of atypical antipsychotic medications in the treatment of AN are encouraging.