Pharmacological treatment of eating disorders
The issue of medication for eating disorders is controversial, especially in the case of anorexia nervosa. In this article we try to clarify when it is appropriate to consider pharmacological treatment and when not, what psychotropic drugs can help with and what they cannot, the fears and doubts they raise and which drugs can be useful for eating problems. We will talk about eating disorders in general and, when appropriate, specific types.
What medication can and cannot do for an eating problem
Let's start by clarifying that a medication, no matter how well-chosen, never modifies the core symptoms of the eating problem: dissatisfaction with one's own body, low self-esteem or insecurities when it comes to relationships are aspects that form the root of eating problems. A pill cannot solve them because they are deep psychological issues and closely linked to the way of being, facing the world and the vital development of the person.
The root of eating disorders
That said, medication can indeed alleviate the anxious, depressive and (to a certain extent) obsessive symptoms that arise from these underlying problems. The intensity of the symptoms can reach such an extent that the brain biochemistry is affected and, either as a cause or consequence of the altered eating behaviour, the balance is lost and, for example, anxiety attacks, obsessive rituals, insomnia or aggression occur. Even hallucinations, in some cases. In these aspects, medication can alleviate these symptoms, while the psychotherapeutic treatment that every eating disorder requires gradually provides tools to identify, confront and resolve underlying conflicts. Medications can help put you in a better mental state to assimilate therapy.
We must consider that many cases arrive at the consultation after a considerable period of development, and often a series of behaviours have already been established to which daily functioning has been (mis)adapted. This means that the initial conflicts become increasingly buried, leaving the food part as the most visible and conspicuous (that is why we use the analogy of an iceberg). Hence the importance of early diagnosis and treatment. Reversing this process is a long one and begins with correcting dietary guidelines. This usually creates a lot of associated fear and anxiety. In these more acute situations it may also make sense to consider pharmacological options.
Much more than a problem with food
Well indicated, medication and therapy are enhanced and we achieve a beneficial synergy that can save time, intensity and suffering. We can, using another analogy, lower the fever while looking for the underlying cause. If we only medicate, the core of the problem will persist. If therapy is only done in an acute case, the highly obsessive mental state and the associated anxiety can make it difficult for the therapy, slower to obtain results, to be assimilated and have an effect. The same happens if we try to reason with someone in a state of intoxication due to having consumed drugs or alcohol. Let's remember that eating problems work like an addiction and, as such, must be treated. Deconditioning learnt responses to an element, food, which unlike alcohol and toxic substances is necessary for life. And these responses, at least originally, had a meaning for the individual. A meaning that is lost in oblivion the more anomalous behaviors take hold. That's why we say that eating disorders catch on, that they "catch".
Fear of taking medication
So in general, there is no need to rush to medicate a person with an eating disorder, nor is there a need to reject this option from the outset.
The main fears that people receiving care and their families express about medication are:
- Will it create dependency? Will it make me sedated?
Dependency and sedation are avoided by carefully controlling the dose and taking it correctly (avoiding overdose), making specific or fixed guidelines depending on the substance that requires it. And by explaining well the difference between the need to maintain treatment to get out of a vicious circle and a physical and psychological addiction at the same time such as that caused by narcotics. There are drugs that the body can get used to and then lose their effect, while others work precisely once the body has gotten used to them and this needs to be explained. - Will it make me fat?
There are some very specific medications that can influence weight gain, but it is something that the referring psychiatrist knows and evaluates in which cases it is counterproductive. The vast majority of medications that we give to treat eating problems do not have a significant impact on weight. - Will it prevent me from feeling or thinking?
Regarding whether drugs can calm feelings, there is a difference between doing so and having thoughts dominated by obsessions with food and the physical body or having emotions overflow and fluctuate like a roller coaster, as usually happens with eating problems. If this happens, it is necessary to assess what to do according to the specific evolutionary moment in each case. In some cases it is better to maintain them, while in others it is appropriate to lower them or even remove them. - If I start, will I have to take it for life?
In principle, no. Medication is recommended while the person with an eating disorder learns how to get out of it, how to detach themselves from abnormal thoughts and behaviors. But there are cases in which it is advisable to maintain the pharmacological regimen. These will be especially those with other associated pathologies (persistent anxiety attacks, OCD (obsessive-compulsive disorder), bipolar disorder, psychotic outbreaks, etc.). There is no general rule, each case must be individualised and it also depends on the evolution and risk or not of the problem becoming chronic.
Properly prescribed and taken correctly, medication is safe
The important thing, we reiterate, is to carefully consider each individual case. Resolve these fears, admit the limitations of the drugs, inform them, and always listen to the person being treated and the family before and after medicating.
Among other things, when choosing a drug, personality factors must be considered, which may determine, for example, not opting for substances with a faster effect but greater addictive potential; or even choosing not to take medication. It is also necessary to take into account the nutritional status and vital signs (heart function, especially in the case of underweight), the type of symptom (vomiting will expel the pills), the associated medical complications (such as sleep apnoea in overweight people) and the profile of potential side effects specific to each drug. The clinical experience of each professional also influences the choice, as does knowing which treatments are supported by accumulated scientific evidence and which are not. And, finally, it is necessary to consider that each person can tolerate a specific medication differently.
We must medicate with specific objectives, to achieve a benefit and reevaluate it. If we think that what we want to obtain (for example, not being afraid of eating) cannot be achieved pharmacologically, we must warn them and not institute unnecessary medication.
It is also essential not to drink alcoholic beverages or take any type of drug while undergoing psychopharmacological treatment, due to the dangerous interferences that could occur. Another important aspect in a child or adolescent with an eating disorder is that the medication is supervised and administered by the parents, to avoid unnecessary risks.
When administered properly and in correct doses adjusted to the need, and without overusing it, medication is generally well tolerated. It is essential to ask any questions to the specialist who proposes it. And it is important that when an adverse effect appears, the doctor and the person being treated speak to one another and seek a solution.
How long should I take medication?
In most cases, pharmacological treatment can be withdrawn as the person improves and acquires strategies to cope with the eating disorder. The experience of positive change will be added, which is one of the most powerful reinforcers to ward off symptoms. The duration for which pharmacological treatment should be maintained will be the time the affected person needs to assimilate and effectively use these tools for change.
And, finally, it is necessary to take into account that the longer the problem has been evolving, not only will we find certain behavioural patterns (regarding food and personal and social functioning) more established, but at the level of brain biochemistry these behaviours can also have future repercussions. For example, the maintenance of low levels of brain serotonin due to a maintained obsessive state could contribute to chronicising the disorder. And since brain neurotransmitters work through a complex network of interconnected circuits, and in the body everything is related, the imbalance of one system can affect others. This fact could be related, for example, to the turn of cases of anorexia to bulimia and binge eating.
What types of drugs are used in cases of TCA?
- Anxiolytics and hypnotics
Useful for reducing anxiety, anxiety about compulsive eating and insomnia. Without ruling out melatonin or herbal remedies which, although less powerful and often insufficient in severe cases, can help in mild cases. - Antidepressants
They increase the cerebral availability of serotonin and other neurotransmitters, which can relieve anxiety and improve mood, ritualised behaviours and, to a certain extent, the circular thinking typical of obsessive states. - Anti-impulsive
Topiramate and other drugs also used in epileptic seizures (consisting of neuronal discharges) can reduce impulsivity towards food in cases of bulimia or binge eating disorder. - Neuroleptics or antipsychotics
In specific cases, they can relieve deep anxieties that are resistant to tranquilizers, unblock when one is very closed in on oneself and deeply distressed, reduce the desire for compulsive hyperactivity or calm aggressive behaviors. In addition to the unusual but serious cases in which a psychotic outbreak appears.
It is always necessary to weigh the need for one or another drug with the person being treated and the family, explain what we hope to achieve and the profile of the most common side effects, and reassess the advisability or not of maintaining the treatment over time depending on the results.
Psychosis in eating disorders: warning signs
What does the scientific evidence say?
Over the years, different pharmacological treatments have been tried for eating disorders. Best practice guidelines from around the world agree that:
- If there is an associated state of malnutrition, it is necessary first of all to reverse this state, at least to ensure the physical stability of the person with the eating disorder.
- There is no specific psychotropic drug for the core symptoms of anorexia nervosa and other eating problems: obsession with food and body, distortion of self-image, dietary restriction, weight phobia.
- In bulimia nervosa and binge eating disorder, there is evidence that some drugs (antidepressants, topiramate) can reduce vomiting and binge eating.
- There is some evidence that medication may be useful in treating the symptoms that accompany or are added to the eating disorder (secondary or comorbid): anxiety, depression and insomnia, mainly, or obsessive-compulsive disorder.
- In an eating disorder, the longer the evolution time, the worse the prognosis.
- The younger the affected person, the more important the involvement of the family and some type of family approach is, especially in anorexia nervosa.
For some medications we need to accumulate more knowledge and studies to decide if they are effective. Others are under consideration or development (lisdexamfetamine and zonisamide for binge eating, metreleptin for anorexia). Finding, for example, drugs that influence the intestinal microflora (which in turn produces substances with neuroendocrine effects that influence mental state) or the agents that regulate appetite and satiety (such as ghrelin, orexin and leptin) is currently a promising line of research.
For other more recently characterised eating problems (ARFID, pica, orthorexia) there are still no recommendations for specific medications, but several are being tried, with variable results, and the results will need to be examined to draw conclusions for or against the different options.
Properly prescribed and properly administered, medication is another tool. A tool that must be prescribed and monitored by a psychiatrist specialising in eating disorders. A tool with pros and cons that must be assessed individually; that will not always be appropriate or necessary and that can also be dangerous; that must be associated with psychotherapy, considering the scientific evidence and that doing so enhances the result, and that can contribute to helping the affected person to gradually free themselves from the trap posed by eating problems.
