Zyprexa for anorexia nervosa?

[futureapppsy2]

The mention of Zyprexa on another thread reminded me of something I read on the use of Zyprexa in AN, for both its weight gain side effects and for decreasing the intensity of the anorexic "voice'" and the resultant anxiety thereof. In your experience, is this common and/or effective, or just a "fringe" treatment?

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[Therapist4Chnge]

The psychiatrists at our facility don't typically use Zyprexa for that reason actually.....as weight restoration needs to be closely monitored and is better controlled through nutrition. The weight gain from Zyprexa can be sporadic and too quick for regular patients, let along pts with AN. I'd be curious to see how other places work though.

As an aside, it is important to distinguish between actual` auditory hallucinations and pervasive/intrusive thoughts that they attribute to their ED. While many ED patients describe their ED as "another self", they can still differentiate between actual "conversations" vs. negative self-talk, etc.

 

[Solideliquid]

There was an article we looked at during a recent Journal club and it showed that 56.2% of people with AN were diagnosed with a co-morbid psychiatric disorder. In fact 33.8% of people with AN had three or more diagnosable psychiatric conditions.

In our clinic we have a psychologist who specializes in ED. He has a few patients that I follow where we have put them on olanzapine not as a primary treatment for weight loss, but for psychotic spectrum symptoms which have resulted due to another condition.


The article is J.I. Hudson et al, BIOL PSYCHIATRY 2007;61:348–358 (Feb). Lots of data from the NCS-R.

 

[whopper]

Comorbid conditions do need to be treated. Comordid depression, anxiety etc should not be overlooked.

From the data I've seen, and from clinical experience from an ED elective, its typically not a good idea to give an ED person a medication simply to cause weight gain unless medically needed-e.g. the person's medical status is to the point where not increasing their weight can lead to their death.

Psychiatrists (as well as other doctors) tend to give the medications within their spectrum of training, but there are other non-psychotropics that can cause weight gain such as cyproheptadine which is sometimes used. To give a medication that is only within the realm of what the person commonly knows simply to cause the common side effect of the medication is IMHO ridiculous. E.g. giving Seroquel simply to help people sleep without regard to what its intended to do, and its possible side effects.

I've heard of psychiatrists without ED training giving out zyprexa simply to cause weight gain. That's an oversimplification on treating Anorexia. That IMHO is falling under the "throwing a pill at the problem" mentality that is hurting medicine these days. Should something of this be tried? Well given a specific situation perhaps, but there's not much good evidence based data backing it up. It also shouldn't be continued if its not working and an adequate period of time has been used.

Another pitfall with medications that are intended to cause weight gain is that most ED patients will demand to know if the medication causes weight gain, the data behind it, and what the FDA approvals are for Zyprexa, none of which are for intended weight gain, an ED or anxiety. Most ED patients, when told a medication can cause weight gain demand to not be put on that medication.

Proper ED treatment is on a multidisciplinary level. Psychiatrists should consider the use of medications, of course including the psychotropics. However psychotherapy should be the core treatment. Psychiatrists should not hesitate to use psychologists, or other M.D.s in treating an ED.

A frustration I had with the ED clinic (that was no fault of their own) was that managed care wanted medications to be tried, and if failed, a new one be tried, or they wanted that person out of the clinic. It was ridiculous. The data behind psychotropics for ED is not very good. Managed care does not want people in inpatient who are only recieving psychotherapy. Psychiatrists at that ED often times gave an psychotropic not even expecting it to work because of the added layer of bureaucratic & non therapeutic demands managed care was placing on them. E.g. an Anorexia patient was having cognitive distortions that she was overweight (not delusions--cognitive distortions which is different). Everyone knew full well it wasn't psychosis, but an antipsychotic was given because the cognitive distortion was labelled as a possible delusion.

 

[surftheiop]

My adult psychopathology professor is also a clinical psychologist who works alot with AN patients. He said in his opinion AN is really an anxiety disorder and for succesful treatment you really need to treat the underlying anxiety.

I was curious if this is a common approach?

 

[whopper]

He said in his opinion AN is really an anxiety disorder and for succesful treatment you really need to treat the underlying anxiety.

I was curious if this is a common approach?

Which IMHO is very true given the frame of references he may mean.

However I don't agree with this on a psychopharm level.

You don't get the type of benefits with SSRIs on an ED that you do with an Anxiety DO. There is plenty of data backing that up.

So yes, ED patients often times do have a lot of anxiety, and I can see what he means (if I'm interpreting him correctly), even agree with it, however it is a different beast than simply an Anxiety DO, because to see it that way may lead one to simply throw an SSRI at the problem.

IMHO an ED is something more along the lines of a Cluster B disorder, and in fact presents very much like Borderline. My reasoning is they often times have a comorbid Cluster B, the core treatment is psychotherapy, and psychotropics while sometimes helping with the symptoms, usually aren't of much benefit. The person often times has several primitive defense mechanisms such as cognitive distortion, and has several aspects of low self esteem. Yes they do suffer from plenty of anxiety like a Borderlines do.

 

[futureapppsy2]

Thanks for the discussion! I know that one recent (and fairly well-supported empirically, IIRC) conceptualization of ED treatment has been to focus on refeeding, especially famiy-based tx, as a way to both restore weight and cognitive functioning (thought to be impaired to the malnutrition) and serve as "exposure," ala ERP, with therapy and meds being seen as primarily supportive mechanicisms and/or ways of addressing comorbidities.

 

[Therapist4Chnge]

Refeeding without concurrent psychotherapy has an incredibly high failure rate. Garner & Garfinkel have done some great work in ED treatment (Handbook for psychotherapy for anorexia nervosa and bulimia).

Here is an excerpt I wrote on Garner & Garfinkel's Cognitive Theory of Anorexia, which also touches on the anxiety component someone mentioned above.....

The Cognitive Theory of Anorexia, developed by Garner and Garfinkel (1985), takes principles from the original cognitive model developed by Beck and his contemporaries (Beck, 1976; Beck et al., 1979) for dealing with depression and anxiety, and modifies them to address the specific challenges of Anorexia Nervosa. Garner and Garfinkel (1985) posited that the central issue involves the belief that, “it is absolutely essential that I be thin” which they consider to be part of a larger set of over-arching, distorted beliefs, attitudes, and assumptions about the role of body weight, which are then manifested in the bizarre and irrational behavior often associated with anorexia nervosa. Garner and Garfinkel (1985) believed that an anorexic individual, because of their focus on thinness and absolute avoidance of fatness, would diet, restrict, purge and/or utilize any other method to avoid weight gain and fatness (1985). This distorted belief system shaped all incoming information and stimuli, making it fit within the current beliefs through the use of distortions, or discarding it entirely (Beck, 1976).

Anorexia Nervosa is unique in that traditional avoidance can only work to a certain point, since the fear stimuli is the self, albeit the self at a higher weight (Garner & Garfinkel, 1985). Complete avoidance and escape is not possible, so instead, hyper-vigilance is sought to combat the fear stimuli(s) (Garner & Garfinkel, 1985). Unlike many other disorders that utilize avoidance, the actual fear and anxiety surrounding the food and weight gain is considered functional to the individual (Garner & Bemis, 1982), as it is a means to control the intake of food in the face of starvation (Garner & Garfinkel, 1985). Weight loss is not only an avoidance of fatness, but it is also symbolic of accomplishment and mastery, so it functions as a cognitive self-reinforcement and offers a sense of control that is typically lacking in the individual’s life (Garner & Garfinkel, 1985). Weight control and/or weight loss is then seen as the primary “barometer of achievement,” and an easy and reliable reference for the individual to evaluate themselves (Garner & Garfinkel, 1985).

 

[FURY 161]

The mention of Zyprexa on another thread reminded me of something I read on the use of Zyprexa in AN, for both its weight gain side effects and for decreasing the intensity of the anorexic "voice'" and the resultant anxiety thereof. In your experience, is this common and/or effective, or just a "fringe" treatment?

http://ajp.psychiatryonline.org/cgi/content/abstract/165/10/1281

 

[masterofmonkeys]

I would think that the last thing you want to do with someone who thinks they're fat when they're not, is actually make them fat. Seems counter-productive.

 

[Anasazi23]

The psychiatrists at our facility don't typically use Zyprexa for that reason actually.....as weight restoration needs to be closely monitored and is better controlled through nutrition. The weight gain from Zyprexa can be sporadic and too quick for regular patients, let along pts with AN. I'd be curious to see how other places work though.

As an aside, it is important to distinguish between actual` auditory hallucinations and pervasive/intrusive thoughts that they attribute to their ED. While many ED patients describe their ED as "another self", they can still differentiate between actual "conversations" vs. negative self-talk, etc.

I use it all the time in my eating disordered patients. It can be an excellent short-term solution. Most ED patients will fight, restrict, vomit, food when they're admitted, and their condition often worsens - which will result in serious medical complications.

 

[Therapist4Chnge]

I use it all the time in my eating disordered patients. It can be an excellent short-term solution. Most ED patients will fight, restrict, vomit, food when they're admitted, and their condition often worsens - which will result in serious medical complications.

The post-hospitalization failure rate for weight retention is over 90% (I believe the citation can be found in the Handbook for Eating Disorders) when there are not additional measures implemented like a residential program. My argument is that many places want to hit the target % of Ideal Body Weight as soon as possible for a D/C, but because they push the weight the pt. becomes more cog. aware right as they get out, which leads them to tank and start the cycle over again. While I know insurance doesn't really like people spending much time in the hospital, providing a more gradual weight gain allows for the pt to adjust, support services to be implemented, and then the pt. gets a fighting chance at trying to get a handle on the situation.

Using Zyprexa introduces another variable into the equation, since pts gain at different rates, in addition to the cholesterol issues as well as avoiding <18 pts (which are quick common in this population). I'd also argue that tube feeding, psychotherapy, and a different regimen of meds would offer a more controlled opportunity for weight restoration and not subject the patient to some of the more serious (and possibly irreversible) side effects of an antipsychotic.

 

[Anasazi23]

The relapse rate is bad regardless of the treatment. Being afraid of side effects of medication, and thus not giving it, is not a solution either. There are many studies showing that olanzapine results in a greater rate of achievement of target weight gain (controlling for environmental treatment), reduces obsessive qualities of the anorexic patient, and higher BMI. Some research shows that dopamine antagonism can reduce anorexic behavior in animal studies.

To dismiss the option entirely due to this over-obsession on cholesterol and diabetes can be more dangerous than the underlying condition, which carries a relatively high morbidity and mortality rate. There are ways of monitoring patients, and predicing which patients will respond most negatively to antipsychotic therapy from a metabolic standpoint.

 

[billypilgrim37]

Wouldn't Remeron be a gentler alternative with most of the same benefit? Looks like there's a handful of small, positive studies. I'm pretty sure the attending on our ED floor doesn't use either.

There aren't a lot of people running around with "Remeron is the Devil" signs.

 

[Therapist4Chnge]

The relapse rate is bad regardless of the treatment. Being afraid of side effects of medication, and thus not giving it, is not a solution either. There are many studies showing that olanzapine results in a greater rate of achievement of target weight gain (controlling for environmental treatment), reduces obsessive qualities of the anorexic patient, and higher BMI. Some research shows that dopamine antagonism can reduce anorexic behavior in animal studies.

I've seen the data supporting Olanzapine's use, though my concern is people jumping on that bandwagon when there are other medications out there that have a chance at producing similar results with a better side effect profile. Remeron (as billy mentioned), is a popular alternative that I think shows promise. I've also seen Lamictal (far from max dosing) show effectiveness in reducing obsessive qualities and mood disturbances, which lessens the frequency of ED behavior. Obviously they each have their draw backs, but I think stabilizing the patient on them, while still addressing their nutritional needs through tube feeding and/or supplement use offers a worthwhile alternative to using Olanzapine.

To dismiss the option entirely due to this over-obsession on cholesterol and diabetes can be more dangerous than the underlying condition, which carries a relatively high morbidity and mortality rate. There are ways of monitoring patients, and predicing which patients will respond most negatively to antipsychotic therapy from a metabolic standpoint.

My gripe with Olanzpine is that many treat it as a 1st line option, when it is far from the go-to choice. Stablization is of the upmost important, though it can also be acheived through other medications. Much like prescribers don't go for Clozeril as a first line option for pts with Schizophrenia, I don't think prescribers should go for Olanzapine for pts with AN when there are other possible alternatives out there.

 

[Anasazi23]

I've seen the data supporting Olanzapine's use, though my concern is people jumping on that bandwagon when there are other medications out there that have a chance at producing similar results with a better side effect profile.

It's not a "bandwagon." It's an effective treatment in the right setting, and for the right patient. Antidepressants as a class have failed to show good efficacy in treating this population.

My gripe with Olanzpine is that many treat it as a 1st line option, when it is far from the go-to choice. Stablization is of the upmost important, though it can also be acheived through other medications. Much like prescribers don't go for Clozeril as a first line option for pts with Schizophrenia, I don't think prescribers should go for Olanzapine for pts with AN when there are other possible alternatives out there.

Again, many treat it as first line because it can be. I don't use a lot of Zyprexa, but when I do, it usually works. It's efficacy is arguably the best of the atypicals.

Serum lathosterol increases rapidly during refeeding, whether or not atypical antipsychotics are given. In this sense, it's true that long-term olanzapine could lead to hypercholesterolemia. However, this medication is rarely used long-term. High cholesterol levels in the anorexic patient have actually been found protective from suicide.

 

[BabyPsychDoc]

Refeeding without concurrent psychotherapy has an incredibly high failure rate. Garner & Garfinkel have done some great work in ED treatment (Handbook for psychotherapy for anorexia nervosa and bulimia).

Here is an excerpt I wrote on Garner & Garfinkel's Cognitive Theory of Anorexia, which also touches on the anxiety component someone mentioned above.....

The Cognitive Theory of Anorexia, developed by Garner and Garfinkel (1985), takes principles from the original cognitive model developed by Beck and his contemporaries (Beck, 1976; Beck et al., 1979) for dealing with depression and anxiety, and modifies them to address the specific challenges of Anorexia Nervosa. Garner and Garfinkel (1985) posited that the central issue involves the belief that, “it is absolutely essential that I be thin” which they consider to be part of a larger set of over-arching, distorted beliefs, attitudes, and assumptions about the role of body weight, which are then manifested in the bizarre and irrational behavior often associated with anorexia nervosa. Garner and Garfinkel (1985) believed that an anorexic individual, because of their focus on thinness and absolute avoidance of fatness, would diet, restrict, purge and/or utilize any other method to avoid weight gain and fatness (1985). This distorted belief system shaped all incoming information and stimuli, making it fit within the current beliefs through the use of distortions, or discarding it entirely (Beck, 1976).

Anorexia Nervosa is unique in that traditional avoidance can only work to a certain point, since the fear stimuli is the self, albeit the self at a higher weight (Garner & Garfinkel, 1985). Complete avoidance and escape is not possible, so instead, hyper-vigilance is sought to combat the fear stimuli(s) (Garner & Garfinkel, 1985). Unlike many other disorders that utilize avoidance, the actual fear and anxiety surrounding the food and weight gain is considered functional to the individual (Garner & Bemis, 1982), as it is a means to control the intake of food in the face of starvation (Garner & Garfinkel, 1985). Weight loss is not only an avoidance of fatness, but it is also symbolic of accomplishment and mastery, so it functions as a cognitive self-reinforcement and offers a sense of control that is typically lacking in the individual’s life (Garner & Garfinkel, 1985). Weight control and/or weight loss is then seen as the primary “barometer of achievement,” and an easy and reliable reference for the individual to evaluate themselves (Garner & Garfinkel, 1985).

I do not have extensive experience in ED management, but I have been responsible for a few, both in Psych and in IM. I also have a deep personal interest in AN, since several of my close friends were affected by it at different points in their lives. I agree with Garner and Garfinkel's theory, and it seems to me that by forcing an antipsychotic down a AN patient's throat - especially the antipsychotic that is well-known to cause metabolic disturbances accompanied by uncontrolled weight gain - can threaten to destroy whatever fragile therapeutic alliance a practitioner might have been able to achieve. IMHO, intensive psychotherapy (preferably with family therapy), careful monitored re-feeding and judicious use of pharmacotherapy to treat co-morbid depression and anxiety would be a better approach.

 

[Therapist4Chnge]

I do not have extensive experience in ED management, but I have been responsible for a few, both in Psych and in IM. I also have a deep personal interest in AN, since several of my close friends were affected by it at different points in their lives. I agree with Garner and Garfinkel's theory, and it seems to me that by forcing an antipsychotic down a AN patient's throat - especially the antipsychotic that is well-known to cause metabolic disturbances accompanied by uncontrolled weight gain - can threaten to destroy whatever fragile therapeutic alliance a practitioner might have been able to achieve. IMHO, intensive psychotherapy (preferably with family therapy), careful monitored re-feeding and judicious use of pharmacotherapy to treat co-morbid depression and anxiety would be a better approach.

Which is also my position.

'sazi mentioned short-term use in one of his posts, which may make medical sense (increased weight, stabilization, etc), though the long-term negative relational impact could undo all of the good and lead to more dis-trust.

 

[whopper]

While I did my elective at the Eating DO clinic, the psychiatrists there mentioned that if you give an anorexic patient a medication for weight gain, they patient would most likely refuse it. The same patients were also obsessive about not being on a medication for weight gain & would inquire about the med's weight gain effects--> forcing a doctor to reveal it.

Since Eating DO patients have cognition, capacity and most of them are not commitable, forcing meds for weight gain is at best, as mentioned, only a short term solution, and usually only reserved for those in a state where forced medication could be accomplished (e.g. life threatening conditions.)

 

[Anasazi23]

Which is also my position.

'sazi mentioned short-term use in one of his posts, which may make medical sense (increased weight, stabilization, etc), though the long-term negative relational impact could undo all of the good and lead to more dis-trust.

This I can certainly agree with. I treat a lot of eating disordered patients in the addiction clinic. Invariably, once they reach outpatient status, they want off the quetiapine, zyprexa, or SNRI/SSRI that's causing them weight gain. Of course, if you have an ED patient that is even willing to attend outpatient f/u and actually waits for the doc's advice before stopping or switching means you have a portion of the battle won already.

The difficult truth is that these patients are notoriously difficult to treat, and often, the condition is relapsing and remitting. Many patients continue to have food issues throughout their entire lives. Many "burn out" to a degree and wind up chronically underweight, but get complimented for it, and stay out of the hospital. In my experience, however, even the weight neutral antipsychotics (if they're indicated) are often not tolerated, as this group tends to be exquisitely sensitive to side effects, or is otherwise somatic to begin with.