Combining pharmacotherapy and psychotherapy in the treatment of patients with eating disorders

Systematic Review of Binge Eating Rodent Models for Developing Novel or Repurposing Existing Pharmacotherapies

Recent advances in developing and screening candidate pharmacotherapies for psychiatric disorders have depended on rodent models. Eating disorders are a set of psychiatric disorders that have traditionally relied on behavioral therapies for effective long-term treatment. However, the clinical use of Lisdexamfatamine for binge eating disorder (BED) has furthered the notion of using pharmacotherapies for treating binge eating pathologies. While there are several binge eating rodent models, there is not a consensus on how to define pharmacological effectiveness within these models. Our purpose is to provide an overview of the potential pharmacotherapies or compounds tested in established rodent models of binge eating behavior. These findings will help provide guidance for determining pharmacological effectiveness for potential novel or repurposed pharmacotherapies.

Psicoterapia como estratégia de tratamento dos transtornos alimentares: análise crítica do conhecimento produzido

O objetivo deste estudo foi empreender uma análise crítica acerca do conhecimento científico produzido sobre a utilização das psicoterapias como estratégia de tratamento dos transtornos alimentares. A partir de buscas nas bases PsycINFO, PePSIC e SciELO, no período entre 1999 e 2011, foram recuperados 35 artigos, categorizados em: psicoterapias breves, grupais, psicodinâmicas, complementares, bem como psicoterapias aliadas a outros tratamentos, como o psicofarmacológico. As abordagens mais frequentemente mencionadas foram psicodinâmicas e cognitivo-comportamentais. A modalidade de atendimento predominante foi a grupal. Ainda que preconizando o uso combinado de diversas estratégias, a literatura é unânime em destacar a importância das psicoterapias no tratamento. A análise crítica evidenciou necessidade de leituras que transcendam a mera identificação de técnicas psicoterápicas consideradas mais eficazes para o tratamento dos transtornos alimentares. Deve-se considerar o contexto mais amplo no qual os tratamentos são propostos, bem como promover um diálogo aberto entre enfoques teóricos, valorizando a pluralidade de saberes e a psicoterapia como prática em permanente transformação.

Is anorexia nervosa a neuropsychiatric developmental disorder? An illustrative case report

We propose the concept that anorexia nervosa is a neuropsychiatric developmental disorder. In support of the concept we present a case report of a 12-year-old girl with high functioning autistic disorder who developed Tourette syndrome and obsessive-compulsive disorder. She subsequently experienced a distinct onset of partial anorexia nervosa characterized by fear of gaining weight, body image distortions, food preference idiosyncrasies including avoidance of fat, dietary restriction, a pursuit of thinness, episodic self-induced vomiting, the missing of her menstrual cycles, and a 10% decrement in expected weight for height. She fell short of the required 15% decrement in expected weight for height to qualify for the full syndrome. Our case presentation emphasizes the longitudinal commonalities and symptomatic overlap of her multiple comorbidities. We discuss treatment approaches typically used with individuals with neuropsychiatric developmental disorders which might benefit higher functioning individuals with eating disorders. We conclude with examples of a neuropsychiatric developmental approach to generate a research agenda for anorexia nervosa.

Pharmacotherapy for eating disorders and obesity

Anorexia nervosa and bulimia nervosa are significant mental health problems in the adolescent population; however, there are no medications approved by the FDA for the treatment of adolescents with either of these disorders. Many medications are used off label for both the symptoms of eating disorders and their co-morbid conditions, particularly SSRIs and atypical anti-psychotics. The dosing, side effect profile, and long term effects of these medications in children and adolescents is unclear. Binge eating disorder, night eating syndrome, and sleep-related eating disorder often are associated with over-weight in adolescents. There are various pharmacological approaches to the treatment of obesity in the adolescent population some of which have FDA approval. In the article the authors discuss pharmacological approaches to guide the treatment of eating disorders and obesity in the pediatric population, including risks of treatment, monitoring of potential side effects, and recent outcomes in the literature.

Evaluation of extinction as a functional treatment for binge eating

Binge eating is a serious behavior problem exhibited by individuals diagnosed with binge eating disorder and bulimia nervosa. Binge eating is thought to be maintained by automatic negative reinforcement in the form of relief from negative emotional responding. Current treatments produce only moderate abstinence, perhaps because they do not attempt to alter the functional consequences of the behavior. Although extinction has been thought impossible with behaviors maintained by automatic negative reinforcement, this study evaluated the application of extinction with binge eating. Four women who reported engaging in binge eating at least twice per week participated. Participants listened to an audio tape recording of the covert verbal behavior associated with their negative emotional responding during the binge to prevent alleviation of the negative emotional responding, thus eliminating the reinforcer in an attempt to reduce the behavior. The procedure effectively reduced frequency of the binges when correctly implemented. Implications and suggestions for future research are discussed.

Eating disorders: an overview of treatment responses and the potential impact of vulnerability genes and endophenotypes

Anorexia nervosa (AN), bulimia nervosa (BN) and binge-eating disorder (BED) are the three main eating disorders. Antidepressants, antipsychotics, anticonvulsants, prokinetic agents, opiate antagonists, appetite suppressants, tetrahydrocannabinol, cyproheptadine, zinc and ondansetron have been tested, and are frequently associated with psychological treatment. Selective serotonin reuptake inhibitors have a proven efficacy in BN and binge eating disorder. Other treatments, such as atypical antipsychotics in AN, anticonvulsants in BN and BED, and naltrexone and ondansetron in BN, may be promising, but lack the appropriate trials. The development of genetic researches in eating disorders may help the clinician to choose the most appropriate treatment in forthcoming years, using genetic polymorphisms of vulnerability genes, those linked to endophenotypes, or genes implicated in the metabolism of the drug treatment.

Baseline personality characteristics of responders to 6-month psychotherapy in eating disorders: preliminary data

OBJECTIVE

The Karolinska Psychodynamic Profile (KAPP) was used for the assessment of the six-month outcome of Brief Adlerian Psychodynamic Psychotherapy (B-APP).

METHOD

Fifty-seven eating disordered women (28 with anorexia nervosa, 29 with bulimia nervosa), were included in the study. The sample was evaluated at baseline (time 0) and after six months (T6) with a clinical assessment and with Temperament and Character Inventory (TCI), Eating Disorder Inventory (EDI-2), State-Trait Anger Expression Inventory (STAXI), and KAPP.

RESULTS

Based on symptomatologic improvement, two sub-groups were obtained: responders (66.6%) and non-responders (33.3%). Significantly higher baseline scores emerged in the responders group on Ineffectiveness and Impulsivity (EDI-2) and on Harm Avoidance (TCI). Several KAPP items and areas improved in both groups at T6.

CONCLUSION

Multimodal treatment centered on B-APP lead to both a global clinical improvement and an improvement in several psychological and psychopathological features as assessed by EDI-2, STAXI and KAPP. The results suggest interesting clinical implications, though outcome predictors are quite weak.

Repetitive transcranial magnetic stimulation: A possible novel therapeutic approach to eating disorders

The two most common eating disorders, anorexia nervosa and bulimia nervosa, are characterized by aberrant eating patterns and disturbances in body image. Treatment involves combining individual, behavioural, group, and family therapies, possibly with medications. Studies have found that medication, chiefly antidepressants, could be of help in bulimia nervosa but the evidence is weaker for use in anorexia nervosa. Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive technique that briefly stimulates or depresses cortical areas within the brain. It has been used in the treatment of various psychiatric disorders, especially major depression, which is a condition that patients with eating disorders often experience as a significant comorbidity. Given that both disorders may share a common pathogenesis, this report proposes that rTMS may represent an alternative strategy for the treatment of eating disorders. Other evidence that supports this notion comes from animal studies that show that rTMS can change feeding behaviours and central neurotransmitters related to the regulation of eating behaviours. Further investigation into the dose, duration and type of rTMS stimulus is needed to verify the efficacy of this intervention in eating disorders.

Stress and hunger alter the anorectic efficacy of fluoxetine in binge-eating rats with a history of caloric restriction

OBJECTIVE

We examined the effect of fluoxetine to suppress binge eating in rats with a history of caloric restriction (CR) and the extent to which this effect was altered by stress and hunger.

METHOD

To detect heightened sensitivity to fluoxetine, young female rats were used to determine a subthreshold anorectic dose (2 mg/kg, intraperitonally). Another group of rats was either fed ad libitum or given multiple CR (to 90% body weight) and refeeding-to-satiety cycles. One half of the rats were then either spared or subjected to foot shock stress before fluoxetine treatment.

RESULTS

A history of CR alone produced bingelike eating on palatable food (p < .001) and, although stress did not affect intake, it rendered CR rats hypersensitive to the satiety effect of fluoxetine. The feeding-suppression was mainly for chow (p < .05) and the effect was abolished if the rats were in negative energy balance.

DISCUSSION

Results support the utility of this animal model to elucidate serotonergic changes linking dieting to binge eating. The diverse effects of fluoxetine on the type of food, and in hungry versus sated rats, suggest alternate brain mechanisms should be concomitantly targeted for improved treatment of binge eating disorders.

Role of selective serotonin reuptake inhibitors in psychiatric disorders: a comprehensive review

The selective serotonin reuptake inhibitors (SSRIs) have emerged as a major therapeutic advance in psychopharmacology. As a result, the discovery of these agents marks a milestone in neuropsychopharmacology and rational drug design, and has launched a new era in psychotropic drug development. Prior to the SSRIs, all psychotropic medications were the result of chance observation. In an attempt to develop a SSRI, researchers discovered a number of nontricyclic agents with amine-uptake inhibitory properties, acting on both noradrenergic and serotonergic neurons with considerable differences in potency. A given drug may affect one or more sites over its clinically relevant dosing range and may produce multiple and different clinical effects. The enhanced safety profile includes a reduced likelihood of pharmacodynamically mediated adverse drug-drug interactions by avoiding affects on sites that are not essential to the intended outcome. SSRIs were developed for inhibition of the neuronal uptake pump for serotonin (5-HT), a property shared with the TCAs, but without affecting the other various neuroreceptors or fast sodium channels. The therapeutic mechanism of action of SSRIs involves alteration in the 5-HT system. The plethora of biological substrates, receptors and pathways for 5-HT are candidates to mediate not only the therapeutic actions of SSRIs, but also their side effects. A hypothesis to explain these immediate side effects is that 5-HT is increased at specific 5-HT receptor subtypes in discrete regions of the body where the relevant physiologic processes are regulated. Marked differences exist between the SSRIs with regard to effects on specific cytochrome P450 (CYP) enzymes, and thus the likelihood of clinically important pharmacokinetic drug-drug interactions. Although no clear relationship exists between the clinical efficacy, plasma concentration of SSRIs, nor any threshold that defines toxic concentrations, but therapeutic drug monitoring (TDM) may be useful in special populations, such as in elderly patients, poor metabolizers (PM) of sparteine (CYP2D6) or mephenytoin (CYP2C19), and patients with liver and kidney impairment. Several meta-analyses have reviewed the comparative efficacy of TCAs and SSRIs, and concluded that both TCAs and SSRIs have similar efficacy in the treatment of depression. SSRIs have demonstrated better efficacy and tolerability in the treatment of obsessive compulsive disorder (OCD). They have also been found to be effective in the treatment for social anxiety disorder both in reducing total levels of social anxiety and in improving overall clinical condition. The benefit of SSRIs in anorexia nervosa (AN) is apparently short-term unless medication is given in the context of nutritional or behavioral therapy. No single antidepressant can ever be recommended for every patient, but in a vast majority of patients, SSRIs should be considered as one of the first-line drugs in the treatment of depression.