Anorexia and bulimia nervosa in adolescents: medical, nutritional, psychological and psychiatric evaluation and management

Introduction

Anorexia nervosa (AN) and bulimia nervosa (BN) in adolescents are serious eating disorders (EDs) that present to the primary care clinician for evaluation and treatment. In this paper we will review the diagnostic criteria, the evaluation and the treatment of the medical, nutritional, psychologic and psychiatric aspects, including psychopharmacologic considerations, of the care of these youth. Safety planning will be described, given the high rate of both suicidal and non-suicidal self-injury in this high-risk population.

Diagnosis and epidemiology

The 4^th edition of the Diagnostic and Statistical Manual (1), published in 1994, included three major ED diagnoses: AN and BN, each of which had specific clinical criteria required for its diagnosis, and eating disorder not otherwise specified (EDNOS), which was applied as the diagnosis for those who clearly had an ED but did not meet the specific criteria of either AN or BN. The specific criteria for AN were: weight at least 15% below expected (for age, height and gender), fear of gaining weight, body image distortion, and amenorrhea of at least 3 consecutive cycles (in those who were expected to have normal menstruation). The specific criteria for BN were recurrent episodes of binge eating (at least twice a week for at least 3 months), inappropriate compensatory behaviors (vomiting, laxatives, excessive exercise and/or intermittent starvation), body image concerns, and a specification that the disturbance is not occurring only during episodes of AN.

Over time, it became clear that the criteria for the diagnosis of AN and BN in the DSM-IV were too restrictive, resulting in a large percent of patients receiving the catch-all diagnosis of EDNOS. In some cases, patients were not at least 15% below expected weight or had not had amenorrhea for 3 months, in order to meet the criteria of AN; in other cases, there was no binging, even though there was purging, or the behaviors had not reached 3 months, in order to meet the criteria for BN. In a study performed in our own institution in 2010, we found that approximately two-thirds of the out-patients who presented for ED evaluation and treatment received a diagnosis of EDNOS, rather than AN or BN (2).

Thus, when the 5^th edition of the Diagnostic and Statistical Manual (3) was published in 2013, a specific goal in the ED category was to make the diagnoses of AN and BN more appropriately match what was being seen in clinical care. This was done in two major ways: (I) a diagnosis of atypical anorexia nervosa (AAN) was added in a section entitled “other specified feeding or eating disorder” (OSFED), to encompass those patients who had AN thoughts and behaviors but were not underweight—and the requirements of amenorrhea and at least 15% below expected weight were removed from the diagnosis of AN; and (II) a diagnosis of purging disorder (PD) was added, also in the OSFED section, to include those patients who purged but did not binge, and the frequency of binging and purging required for the diagnosis of BN was decreased to once a week. In addition to these changes, a new diagnosis of avoidant restrictive food intake disorder (ARFID) was added, to include those patients who ate poorly for reasons unrelated to fear of weight gain and/or body image concerns.

The authors of this current paper have recently written review articles on ARFID (4-6), so a discussion of this diagnosis will not be included here. Also not included will be a discussion of binge eating disorder (BED), a diagnosis that was included preliminarily in the DSM-IV and permanently in the DSM-5 but is not seen frequently in adolescents. Rather, this article will focus on the diagnoses of AN, AAN, BN and PD. It should be noted at this point that the DSM-5 has, in fact, done an excellent job—with the 6 diagnoses of AN, AAN, BN, PD, ARFID and BED, the catch-all diagnosis of EDNOS has been eliminated from the contemporary vocabulary in describing ED diagnoses. It should also be pointed out that while AN and AAN, as well as BN and PD, are different diagnoses, there is a large amount of overlap in how they are managed clinically; we will point out those circumstances in which they are managed differently in this paper.

From a demographic perspective, approximately 90% of patients with AN/AAN and BN/PD (but not ARFID or BED) are female (7-9). It is estimated that the former occurs in 0.5% of females, more commonly in adolescents than young adults, while the latter occurs in 1–3% of females (more commonly in young adults than adolescents). It is believed currently that those who are gay, transgender or non-binary have higher rates of AN/AAN and BN/PD than others (10), it has been shown over the years that those with all eating disorders (EDs) are disproportionally from higher socioeconomic status groups (although this appears to be changing with time) (11); and studies have shown that in the United States race and ethnicity play a role in the demographics of EDs, with those from White or Asian communities having greater numbers of patients with EDs than those from Black and Hispanic communities, although this too may be changing as the demographics of the country are changing over time (7).

Medical evaluation and treatment

In the simplest terms, the greatest medical concerns for patients with AN/AAN are the effects of malnutrition and the greatest concerns for patients with BN/PD are the effects of purging (and/or laxative use). The medical history, evaluation of the growth curve, physical examination, and laboratory (and other) testing are utilized to determine the medical steps that need to be taken for each individual patient with an ED.

In obtaining the history from a patient initially being evaluated for an ED, it is important to cover many parts of the story, including the nutritional and psychologic/psychiatric aspects (to be discussed in later sections of this paper) and it is advisable to include one or both parents in the discussion (since the history provided by the patient may be neither complete nor fully accurate as many adolescents may be in denial of their disorder and may not want to let either their parents or their clinicians know the details of what they are doing and what they are thinking) (12). How and when weight loss and/or decreased eating took place should be reviewed chronologically; details of why those occurred should be explained in detail; questions regarding how the patient feels about regaining weight and improving eating currently should be asked; and participation in specific behaviors (binging, purging, laxative or diuretic use, exercise and starvation) should be determined. Major goals of obtaining the medical history are to be fully aware of the ED behaviors and thoughts over time, to determine that the patient does in fact have an ED rather than another medical or psychiatric condition that accounts for their findings, and to evaluate both the specific ED diagnosis and the severity of the condition.

In the evaluation and on-going treatment of many patients with EDs, especially younger adolescents with AN or AAN, it is very useful to obtain growth curves which show the changes in weight, height and body mass index (BMI) that have taken place over time. This allows for a determination of such things as whether the patient was underweight, average weight or overweight before the onset of the ED, whether growth in height has been affected by the presence of the ED, and what the goal weight for the individual patient should be. Clinically, determining how much total weight was lost and calculating percent of expected weight (% EBW) are most useful in determining day-to-day management of each individual patient.

Although amenorrhea is no longer one of the criteria in determining the diagnosis of AN, obtaining a menstrual history remains a crucial component for female patients with EDs. Most female patients with AN, and many with AAN as well, develop amenorrhea as a result of their weight loss and malnutrition. Ultimately, it is return of menses that becomes a key part of the clinical goals for the treatment of these patients. It is known that for patients with AN who began at normal weight, return to that weight (or close to it) will likely be required for return of menses, while for patients with AAN who were overweight before the onset of their weight loss, return to a weight between average weight and starting weight will likely be required (13-15).

One further part of the medical history is obtaining a complete review of systems (ROS). Patients with AN/AAN will often display several symptoms due to their malnutrition. Many patients have orthostatic symptoms, decreased energy and fatigue, and almost all patients develop gastrointestinal (GI) symptoms, including abdominal pain, bloating, fullness and/or constipation (16,17). Studies have shown that there is delayed gastric emptying and abnormal peristalsis in patients with weight loss/malnutrition, resulting in the above symptoms. While the GI symptoms are seldom dangerous, they often become a focus of the patient’s (and family’s) attention (17). We explain to patients and families that for those who never had GI symptoms before the onset of the ED, they are very likely to develop them during the course of the ED, while for those who had functional GI symptoms before the ED, they will likely get more during the ED. We explain further that improved eating and increased weight are the required treatment for these symptoms.

A complete physical examination is performed on those being evaluated for the presence of an ED. This includes a determination of the patients’ vital signs, including weight, height, blood pressure and pulse. The latter two may be decreased, especially in those with severe malnutrition, as the body’s way to conserve energy; significant bradycardia and orthostatic hypotension may serve as indicators for those patients who may require hospitalization for stabilization of their malnutrition (16). An electrocardiogram (EKG) is performed in some, but not all, patients with EDs, most commonly in those with AN/AAN with bradycardia, or in those with BN/PD with hypokalemia.

Laboratory testing is also performed in the evaluation of patients with EDs. A complete blood count (CBC), comprehensive metabolic panel (CMP) and thyroid function tests (TFTs) are most commonly ordered. The CBC is normal in most patients with EDs, with the amenorrhea of AN helping to protect against the development of anemia, but the white blood cell and/or platelet counts can be decreased in those with the most severe levels of malnutrition. The CMP is likewise normal in most patients with EDs; the most important exception to this is finding of hypokalemia in some patients with BN or PD. While hypokalemia is not a frequent finding, occurring in only a small percentage of patients with BN/PD, it can be life threatening, and always needs immediate treatment. It is therefore crucial that a CMP be performed in the initial evaluation of patients with EDs, especially those in which purging is, or is suspected to be, one of the ED behaviors. Other abnormalities that can be found on the CMP include hyponatremia, in those patients who water-load enough (either as a way to quench hunger but more often to fool the doctor’s scale) to lower their sodium levels, and elevated liver function tests (LFTs), which can occur during either the malnutrition or refeeding phase of the disorder. TFTs usually show very specific abnormalities in patients with malnutrition: TSH is low or low-normal (due to a central shutdown aimed at conserving body energy), T₄ is also low or low-normal, and T₃ is lower than T₄ (due to a euthyroid sick syndrome that occurs in addition to the central shutdown).

Additional laboratory tests are performed in those patients with EDs who have amenorrhea; these are luteinizing and follicle stimulating hormones (LH/FSH), prolactin and estradiol. The first three are performed to confirm that there is no other cause of the amenorrhea (we have seen cases, albeit rarely, of elevated LH/FSH or prolactin) and a low estradiol confirms that the malnutrition is in fact the cause of the amenorrhea. Ultimately, it is the low estradiol that leads to the one major long-term consequence of AN, which is the development of osteopenia/osteoporosis that has the potential to affect patients several decades after the resolution of their ED (i.e., worsening or earlier development of clinically significant osteoporosis after menopause due to improper development of bone density during the adolescent and young adult years when bone development is expected to be strongest). Unfortunately, neither calcium nor vitamin D nor exercise nor estrogen in the form of birth control pills are effective in countering the effects on bone of the amenorrhea during the course of the ED; the only truly effective treatment to limit the damage is a return of normal eating, normal weight and normal periods.

In performing the medical evaluation of a patient with a likely ED, it is important to keep in mind the differential diagnosis of other medical conditions that can cause weight loss and/or vomiting. These especially include GI conditions (inflammatory bowel or celiac disease), endocrine disorders (Addison’s disease, hyperthyroidism, diabetes mellitus) and brain tumors or other occult malignancies. Specific testing is not done for each of these conditions in every patient; rather, additional testing [such as an endoscopy or magnetic resonance imaging (MRI) of the brain] is done in the those where there are indications of another medical condition, or the ED does not fully account for all symptoms. The differential diagnosis can also include other psychiatric conditions. Thus, it is important to distinguish between the patient who won’t eat because of fear of weight gain versus the patient who can’t eat because of depression or the patient who refuses to eat because of concern that the food has been poisoned, the latter due either to psychosis or severe obsessive-compulsive disorder (OCD). It should also be noted that while many decades ago the diagnosis of an ED was nullified by the presence of another medical or psychiatric diagnosis, it has been well established since then that the diagnosis of an ED can occur in the presence of a comorbid medical condition and usually does occur with the presence of a comorbid psychiatric condition.

The main medical treatment for patients with EDs involves nutritional rehabilitation, which will be discussed in the section that follows. In addition, the specifical medical symptoms and findings discussed above (including electrolyte abnormalities and/or GI symptoms) may each need to be managed specifically. Also, patients with the most severe levels of malnutrition can be at risk of developing refeeding syndrome (which can include stupor or coma or heart failure if refeeding is done too quickly); this risk generally applies to those who are being treated as in-patients (rather than out-patients) and is due to the development of hypophosphatemia.

Nutritional assessment and treatment

Nutritional rehabilitation is an essential component of ED recovery (18). The degree of nutritional and medical compromise informs the clinical team in determining how to proceed with ED treatment and what level of care is recommended.

A comprehensive nutrition assessment consists of gathering information about the patient’s current and previous eating patterns (and duration of each) as well as specific details regarding types and amounts of foods and beverages consumed, the timing of meals and snacks, eating environment, preparation methods, and origin of meals, i.e., specific restaurants, brands or a specific person’s cooking. Many patients with EDs prefer to prepare their own meals, so it is not uncommon for the patient to be the sole preparer of their meals. Eating-related behaviors are also assessed, including calorie counting, fasting, weighing or measuring food, chewing and spitting, binging, purging, excessive use of condiments or spices, excessive water consumption and exclusion of certain foods or food groups.

The patient’s level of activity is assessed individually and in relation to their eating pattern, and use of dietary supplements and medications (prescribed and available over the counter) is evaluated for appropriate use or misuse. Information is obtained both directly from the patient as well as accompanying parents or family members. Including family members in the nutrition assessment is extremely valuable as the patient may not be forthcoming or may not remember all foods they consumed prior to the development of the eating disturbance, or how their eating patterns and behaviors have changed over time. Patients who binge and purge may not recall what triggered them in certain instances, whereas a family member may be perceptive to changes in eating pattern or mood that contributed. Additionally, family members are highly involved in implementing a nutrition care plan for patients at home, whether the patient is being cared for in the outpatient setting or was recently discharged home from hospital care, a residential treatment center or an intensive outpatient program (IOP).

When discussing and exploring the patient’s eating patterns and food beliefs, one must be cognizant of psychological triggers, which could include certain foods, food groups or environmental and social factors. Eating in front of others may be especially challenging for some patients, leading to lengthy periods of time between eating occasions. Other factors affecting the patient’s nutrition intake and health status are investigated, such as nutrition misinformation and food- or body-related rituals before, during or after meals.

The aim of nutrition rehabilitation is to return the patient to an appropriate body weight, and an appropriate and flexible eating pattern that is not restricted to any degree and is not influenced by body image concerns or psychological distress. The latter applies both to patients with AN/AAN or BN/PD. Balanced eating, i.e., obtaining nutrition from all food groups, is addressed; however, foods are not viewed as healthy/unhealthy or good/bad, as all foods provide nutrition. While the aim of nutrition rehabilitation is valid for all ED recovery, nutrition care is managed differently depending on the level of acuity and treatment setting. However, in all levels of care, weight restoration will require an above-average level of calories, which in turn leads to larger-than-average portions from all food groups, and especially from those foods with a higher nutrient density. The vast majority of patients initially experience some degree of GI discomfort as part of the refeeding process, e.g., early satiety, stomachaches, bloating, nausea. This occurs even as total nutrition is advanced incrementally, and patients are educated regarding this expectation, and how these symptoms normalize over the course of nutritional rehabilitation.

In the outpatient setting, a nutrition care plan is established that increases total calories in an incremental fashion to achieve weight restoration and addresses food-related fears and behaviors. The treatment team, family and patient may share meal planning responsibilities, and over time the patient makes choices independently and requires less and less support from the treatment team and family. In some modalities of outpatient treatment, such as family-based treatment (FBT), the patient may be initially excluded from much of the nutrition planning, as the family members are responsible for preparing, providing and monitoring all meals and snacks.

In a residential treatment center, day program or IOP, the eating environment is more structured and the patient has fewer opportunities for independent choices. The patient must adhere to specific meal schedules and planning guidelines in order to meet calorie needs and obtain nutrients from all five food groups. All meals and snacks are consumed under supervision and guidance of the staff. Foods that have been restricted or eliminated as part of the ED are reintroduced. Addressing these food challenges may occur sooner than in an outpatient setting, as the patient is in a therapeutic environment with supports available to cope with these psychological triggers.

In the hospital or inpatient setting, medical stability is primary, and the patient has little to no choice regarding the content of meals and snacks. Nutrition care is managed precisely and as such, total calories are advanced more quickly in this closely monitored setting. In order to achieve weight gain in a severely malnourished individual, total daily calories may need to be well above maintenance range and typically reaches 3,000 per day or more, as may be true in the out-patient setting as well. Achieving this level of intake may include nutritional supplements to boost total calories, and supplements are used to account for any amount of solid food the patient is unable to consume. In the case of food refusal in the in-patient setting, use of a nasogastric (NG) tube may be required.

Assessment of the psychological and psychiatric aspects

The clinical evaluation and care of children and adolescents with an ED is sufficiently complex to present a major challenge for any practitioner treating these patients in primary care. Healthcare professionals may not sufficiently appreciate the serious nature of ED in this population. Despite what is often viewed as simply self-imposed dietary restrictions, EDs are conditions that carry a high rate of serious medical complications and substantial risk of death.

The clinician is faced with a variety of questions to address in the assessment of the youth. How does one decide what the suitable level of care is? When should a child or adolescent with an ED (e.g., anorexia, anorexia nervosa, AN) be treated in the hospital? When does the physician recommend to change the level of care and either transfer a patient to a less or more restrictive program or discharge the patient to services in the community? How do mental health providers balance the often-conflicting viewpoints of patients and their families. These questions will be examined the sections below.

A wide range of treatment options is available on an outpatient basis for those individuals who can safely be managed outside of a hospital setting (19) (e.g., hospitalization, program). Outpatient care for an ED (e.g., AN, bulimia, bulimia nervosa) can and generally does include a combination of individual [cognitive behavioral therapy (CBT) (20) and/or dialectical behavioral therapy (DBT) (21) and/or group psychotherapy, family therapy (FBT) (22)], nutritional counseling, medical monitoring, and psychopharmacology when indicated (23).

Most children and adolescent with an ED are treated in an outpatient setting. Certain clinical symptoms require treatment in an inpatient unit. Whether this will be on a medical (or adolescent) unit, a general psychiatric unit, or a dedicated ED unit will reflect not only certain clinical considerations but also facility availability (24).

The clinical considerations in outpatient vs. inpatient treatment relate to the severity of the symptoms of the ED (e.g., AN) and their biological concomitants, co-morbidity concerns, the course of the illness, and the degree of compliance with and response to prior treatment. The behavioral aspects of the disorder, namely, the self-starvation, the eating rituals, the excessive exercise, and the possible purging activities will typically fall along a spectrum of severity, as will the consequent physiological aberrations. The American Psychiatric Association released updated Practice Guidelines for the Treatment of Eating Disorders in 2023 (19). These guidelines outlined the clinical parameters for the indication for a higher level of care based upon laboratory findings, vital sign abnormalities as well other considerations. When the behavioral issues are particularly prominent, admission to an inpatient unit, whether general or specialized, becomes medically necessary (25).

Planning for the appropriate level of care

The clinical expertise and formalized treatment protocols that characterize most dedicated ED units make admission to such a setting seem the obvious choice for inpatient treatment. Few regions may have a specialized ED unit, however, whereas general psychiatry units are more widely available. Admission waiting time may be shorter for a general unit because of the more rapid turnover rate characteristic of acute inpatient services. Very young patients (those under 16 years of age) cannot be admitted to a general adult unit but rather to an adolescent medicine unit. Finally, not all general psychiatric units are experienced in treating ED youth. Staff may be unprepared for the behaviors of some of the patients with AN or BN.

An eating disorders unit (EDU) staff is prepared to provide multi-modal treatment that can address the various facets of ED (e.g., AN). This will include such approaches as: CBT, FBT, group therapy, therapeutic activities, psycho-education, nutritional counseling, and pharmacotherapy. An appropriate dietary schedule (often with small multiple feedings), use of liquid nutritional supplements, and restrictions of bathroom access to try to prevent self-induced vomiting after meals. Similarly, the common weekly weight gain target of two to three pounds is carefully monitored on the unit.

In the presence of an imminent suicide risk, a psychiatric admission for a youth with an ED is considered. Nearly fifty percent of children and adolescent with an ED meet criteria for co-occurring major depression at some time during the course of illness (26). The medical indications for hospitalization often include significant weight loss, usually to below 75% of ideal body weight (27). In addition, poor motivation to participate in outpatient treatment with a progressive overall downhill course; or purging with emetics, laxatives, or diuretics that threatens the youth’s medical stability, may be indications for medical hospitalization.

If the patient is fully uncooperative with the treatment regimen and their weight continues to drop, the staff must be prepared to take more aggressive steps to insure adequate nutritional rehabilitation. NG feeding is commonly applied when the patient has either failed to make the necessary weight gain or refused to eat. Rarely, total parenteral nutrition can be considered for seriously ill malnourished individuals, often requiring medical intensive care treatment.

The age of the patient may determine where the locus of responsibility lies for ongoing medical decisions. Refusal of life saving care can become a clinical concern. Parents of those under 18 years of age must consent for the appropriate care for their dependent children. Parental medical neglect can lead to reporting to the child protective agency (28). On occasion, it may be necessary to petition for emergency care even over the objection of the family when the family is not able to provide for the safe treatment for their loved one. In certain situations, it may also be that the identified patient is the victim of abuse, and the family will not acknowledge this. Thus, the clinical decision-making requires an understanding of the history of the illness, as well as familiarity with the family structure, history, and dynamics. In our experience, family involvement is essential for the understanding and ultimate recovery of the patient (24).

The clinical advantages of day treatment for some individuals with EDs can include that youth are not removed from their usual evening/weekend environment and can continue thereby to receive support of family and friends. They can also maintain the opportunity to function normally in at least certain areas of their lives, separate from their illness (for example, school or part-time work). For these patients, regression and dependence on the inpatient unit may be avoided, as the individual is required to self-regulate and self-monitor whenever not in the day program. Thus, during evening hours, weekends, and holidays, these young people can remain involved with their ongoing lives, roles, and relationships. This may contribute to more independence and also to more ready generalization of newly learned behaviors, attitudes, skills, and strategies from treatment setting to real life setting. At the same time, the patient has the support of the group treatments and the program staff to help process, understand, and manage the difficulties of everyday living in the community.

Clinically, day treatment programs may be important for those (patients) for whom outpatient care has not been intensive enough or without sufficient structure to provide for improvement. The individual needs to be evaluated by a physician to assess overall medical stability and to rule out such medical concerns as dehydration, electrolyte disturbances, cardiac problems, and acute medical complications of malnutrition (25,29).

Transition from one level of care to another requires consideration of a variety of factors. The “how, what, where, and when” of the practical decision-making process concerning day program or partial hospital has not been well defined in the literature. For some, it may rest on the availability of these services in their community. The admission to a day program has been most successful in our own experience when it serves as a transition from inpatient care (29). In our clinical setting, we have observed that, following inpatient care, ED patients tend to be less resistant to the day program than those who were not hospitalized. In addition, following discharge, individuals in our program are often delighted to be out of the hospital and able to sleep at home and resume their (normal) lives.

In our own experience, it is often difficult to achieve most of the weight restoration for severely malnourished individuals in a day treatment setting. However, each person’s motivational level and family environment needs to be appreciated. Careful monitoring of the course of treatment allows for the possibility of re-hospitalizing those individuals who fail to meet their treatment goals in a day program.

Trauma and EDs

As is known both clinically and from the research literature, youth with EDs sometimes report histories of childhood sexual abuse; however, no direct relationship has been established (28). Researchers have examined sexual, physical, and emotional abuse as factors contributing to the pathogenesis of EDs.

In children and adolescents, EDs have a variety of predisposing, precipitating and perpetuating factors, such as histories of abuse or neglect. Other critical aspects include but are not limited to genetics and neurobiological changes, personality, and family traits, as well as co-occurring anxiety and/or depressive symptoms.

Patients with a history of childhood abuse are more likely to purge, self-harm, and have psychiatric comorbidity. Abuse is more often reported by individuals with BN than AN. Teens with AN who purge report childhood abuse more often than those who restrict. Overall, rates of reported abuse in both ED and general psychiatric populations are comparable.

Childhood abuse is a non-specific risk factor for EDs. Patients who report childhood abuse are more likely to purge, self-harm, or have psychiatric co-morbidities; therefore, treatment of these patients must address trauma and its sequelae for the individual and family (30).

Safety planning

The potentially life-threatening issues of suicidality, suicidal behavior, non-suicidal self-injury and safety remains a challenge when treating youth with an ED. All health care professionals who are treating patients with an ED must now be aware of the serious risks of suicidal behavior and of suicide in this high-risk population.

Several investigators have suggested that suicide is the major cause of death among patients with AN, refuting the assumption that starvation generally threatens the life of these patients. The implications for assessment and treatment of individuals with an ED who have a history of suicidal ideation, a serious suicide plan, and/or a history of suicide attempts, require special consideration (26).

The rates of parasuicidal behavior, which includes suicide attempts, self-injurious behavior, and deliberate self-harm (cutting, burning, biting, hitting, choking) and intense suicidal ideation, differ. The range of contributing variables includes severity of depression, history of laxative abuse, anxiety, obsessive-compulsive behaviors, hostility, paranoid ideation, alcohol/drug abuse, antisocial behaviors, and low cholesterol levels. The relationship between traumatic experiences and the development of EDs confirmed childhood sexual abuse to be a significant, but nonspecific, risk factor for the development of an ED in adolescents and adults of both sexes. To care for individuals with an ED, it is essential to understand what coexisting psychiatric disorders are present to plan treatment effectively. Rarely do EDs occur as the sole form of psychopathology. Depressive and anxiety disorders as well as substance abuse are frequently encountered.

Several considerations may contribute to the fact that nearly one-quarter of all ED patients give a current or history of substance abuse. Others may abuse amphetamines in their drive for thinness. Some become dependent on benzodiazepines to fall asleep. As reported, EDs are associated with high rates of comorbid psychopathology including mood disorders, anxiety disorders, substance abuse, and personality disorders and, in turn, these frequently present illnesses have been associated with both suicidal and parasuicidal behaviors, as well as suicide. ED patients with serious comorbid psychiatric conditions (especially suicidal ideation or intractable depression) may not only require admission to an inpatient facility but may also be extremely challenging for mental health practitioners. During the assessment phase, particularly with children or adolescents who may be quiet during the family assessment, it is imperative to talk in private with the child/adolescent and question directly for any possible suicidal thoughts and any history of abuse. Also, critical to consider are the ethical and legal issues surrounding treatment compliance and refusal, by either the child, the adolescent, or the family of the individual with an ED. The need for the mental health practitioners to continue outpatient treatment or to hospitalize even against the patient’s or the family’s wishes when lives are at risk remains a therapeutic challenge for the treating clinicians. Understanding the family history of psychopathology and suicidal behavior is often critical to the proper clinical care of the adolescent with an ED.

The clinical assessment of a child or adolescent with an ED must include safety planning. This can be accomplished with a clinical interview as well as the incorporation of standardized suicide screens. The clinician must conduct a risk assessment that identifies specific individual characteristics and environmental features that may increase or decrease the risk for suicide. This will address the individual’s immediate safety needs and indicate the most appropriate setting for treatment. When an individual at risk for suicide leaves the care of the hospital, the parents and youth must be provided with suicide prevention information (such as a crisis hotline).

As has been mentioned earlier, rarely do EDs present as the sole form of psychopathology. The associated comorbidity generally found in this population may likely be related to the increased risk of suicide. Clinician awareness of the heightened risk of suicide in ED patients is critical during the assessment and the ongoing treatment of these individuals. It is sometimes necessary to intervene against the wishes of both the patient and even the family, who have given up hope of recovery. The legal capacity of the clinician to do so may vary country to country, depending on the mental health laws of the region. When the clinical course reaches an impasse, obtaining outside consultation, such as a second opinion, may enhance the clinical care and support the treating clinician. It is imperative that the clinicians not contribute and unwittingly collude with the patient and the family. This is a complex and challenging population, and the clinician, working in a collaborative team, would be supported to prevent the possible demoralization of the therapist. The suicide of any patient, including an ED patient, when in treatment, is a crisis for the clinician. It is recommended that discussion in supervision, peer group, or during a team meeting may help the clinician work through this difficult clinical experience (26).

Psychopharmacological treatment

AN

Currently, there is no clear evidence for the efficacy of pharmacotherapy for the core symptoms of AN. Pharmacological agents are chosen based on their ability to enhance weight gain, reduce anxiety and/or improve mood. Antidepressants and second generation antipsychotics, as well as other medications, will be reviewed in this paper. Most of the studies have been conducted with adults, and the results are extrapolated to adolescents.

The treatment course of AN is begins with medical stabilization. Subsequently, recovery addresses weight maintenance which requires a focus on the psychopathological symptoms of the illness. This treatment includes psychotherapy, education and nutritional rehabilitation, with pharmacotherapy in an adjunctive role. In exploring the “core” AN symptoms, a possibility exists to discover clues to aid in the development of more effective drug treatment.

Antidepressant medication

The antidepressant class of medications has received the most extensive study among psychotropic agents in the treatment of AN. Although this research is not yet exhaustive, most antidepressant trials conducted to date have yielded negative findings. Patients with AN frequently have comorbid psychopathology which in itself might be an indication for the use of an antidepressant medication, including major depressive disorder, anxiety, and obsessive-compulsive disorder.

Early controlled trials failed to demonstrate the superiority of tricyclic antidepressants (TCAs) over placebo. Clomipramine increased hunger ratings during the first 2 months of treatment but was equal to placebo during the final three weeks of the study.

The specific serotonin reuptake inhibitors (SSRIs) have largely supplanted TCA use in the field of psychiatry. In patients with AN, there are additional issues related to TCA use that should be considered. First, it has been reported that underweight patients are at higher risk of developing an arrhythmia with TCA use. Secondly, many patients with AN are adolescent and TCA’s have been associated with sudden death in children. Finally, all antidepressant medications now contain a Boxed Warning regarding an increased risk of suicidal thinking and behavior in children, adolescents, and most recently also in young adults between the ages of 18 and 24 years (31). This warning has been instituted in response to a request from the U.S. Food and Drug Administration (FDA). This risk appears to be highest within the first two months after initiating treatment with an antidepressant.

SSRI’s have been studied in the treatment of AN. There are essentially two types of trials with SSRIs; acute treatment trials and maintenance trials. Acute treatment typically occurs in patients who are often severely underweight and are hospitalized, and the primary treatment goal is weight gain. Maintenance treatment occurs after weight restoration has occurred, and the primary goal of treatment becomes relapse prevention. There are currently controlled data with fluoxetine both in acute treatment and as maintenance treatment. There are also uncontrolled data with a variety of other SSRIs. SSRIs have been studied in weight restored patients with AN. There is equivocal evidence regarding their use in the latter role.

Atypical antipsychotics

The second class of compounds that are clinically used in AN treatment is antipsychotic agents. Second generation antipsychotics (SGAs) have demonstrated some promise in uncontrolled reports and modest trials. As with antidepressants, the weight gain side effect of the SGAs contributed to interest in these agents. Symptoms of anxiety surrounding meals, obsessive features and sleep disruption have been reported to improve with atypical antipsychotic use. While they are not devoid of side effects, the SGAs are generally less likely to cause parkinsonism symptoms, dystonia, and akathisia as well as being less likely to cause tardive dyskinesia (TD). It remains unclear why SGAs are helpful in AN. Is it weight gain, rather than the drug therapy, that may be responsible for these improvements? Or might the drug’s effect in reducing the core symptoms of the illness be the critical factor? This remains unanswered. The trials of the antipsychotic medication olanzapine are associated with modest weight gain (32).

Other medications

Medications other than SSRIs and SGAs have also been tried in a handful of controlled trials in AN. Owing either to unfavorable adverse effect profiles or to a lack of demonstrated efficacy, these medications have not earned a place in the clinical management of AN. Medications in this category include: tetrahydrocannabinol, naltrexone, clonidine, and the prokinetic agents metoclopramide, domperidone, and cisapride. Although the results of the studies with zinc showed benefits on some outcome measures and not on others, the risk of side effects with zinc is low, potentially creating a favorable risk-benefit ratio and warranting consideration of its use.

The current state of pharmacotherapy for AN remains unclear (31). In summary, investigators have studied a variety of medications to determine whether the evidence supports pharmacotherapy in AN. In the absence of such evidence, nutritional rehabilitation remains the essential treatment, however, challenging the AN’s core symptoms. Notably, despite the lack of empirical support for the majority of psychotropic medications, many individuals with AN receiving treatment are prescribed medication, suggesting a disconnect between research findings and clinical practice (32).

BN

Fluoxetine has been shown to be effective in the treatment of BN. This work has been conducted with adults and the results are extrapolated to the treatment of adolescents (33,34).

Conclusions

Adolescents and young adults present to the primary care physician for their routine healthcare, and the clinician is often in the position of suspecting or diagnosing an ED. We have reviewed the recommended assessment and treatment approach for these young people, emphasizing the need for monitoring both medical and psychologic safety. We strongly recommend including the family in the treatment of this population, regardless of the age of the patient (35,36). The primary care physician is advised to work together with a multidisciplinary team including psychiatry, psychology, social work, and nutrition, to assess and care for the various clinical aspects of these vulnerable individuals.

Acknowledgments

None.

Footnote

Peer Review File: Available at https://pm.amegroups.com/article/view/10.21037/pm-24-29/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://pm.amegroups.com/article/view/10.21037/pm-24-29/coif). The authors have no conflicts of interest to declare.

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