May 15, 2019
In Episode 59 Patricia Westmoreland, MD, gives a masterclass
lecture on managing severe and enduring eating disorder
Renee Kohanksi, MD, poses the question, "What do we want?"
Contact us: firstname.lastname@example.org
By Jacqueline Posada, MD, 4th-year resident in the department of
psychiatry & behavioral sciences at George Washington
Westmoreland, MD: forensic psychiatrist at University of
Colorado Denver, Aurora; attending psychiatrist for Eating Recovery
Center, Denver; and adjunct assistant professor at University of
Colorado Denver in department of psychiatry.
Dr. Westmoreland spoke at the
American Academy of Clinical Psychiatrists 2019 annual meeting
in Chicago, sponsored by Global Academy for Medical Education
(GAME). GAME and the MDedge Psychcast are owned by the same
Introduction, definition, role of involuntary treatment,
and novel treatment options
- Prognosis: Anorexia nervosa (AN) has the highest mortality of
any psychiatric disorder.
- Risk factors for death: Older age at first presentation, lower
weight at presentation, greater duration of illness, comorbid
alcohol or diuretic abuse, comorbid mood disorder, history of
psychiatric hospitalization and suicide attempts, and self-harm.
- Less than 50% recover completely, about 30% improve somewhat
but require frequent hospitalizations or treatments, and 20%
develop a SEED.
- Eddy et
al. longitudinal study of eating disorders (EDs): AN
patients can recover over the long term. Overall, 31% were better
at 9 years; 63% better at 22 years of follow-up.
- Treat ASAP, especially if patient is seen at a young/pediatric
age before symptoms are fully developed and weight loss is
- Weight gain as the central treatment: Many patients are
reluctant to get treatment that focuses only on food intake and
- Predictors of improvement: Weight gain that is parallel to
improvement in physical and psychological well-being, diagnosis at
a younger age, and shorter duration of illness.
- Medications: Fluoxetine is the only Food and Drug
Administration-approved treatment for EDs, including bulimia, at
doses of 60 mg and above.
- Patients with EDs have poor response to selective serotonin
reuptake inhibitors because of starvation and limited production of
serotonin and serotonin receptor abnormalities.
Severe and enduring eating disorders (SEED) definition:
- 6-12 years of an ED can qualify as chronic.
- Lower likelihood of recovery with symptoms substantially
interfering with quality of life.
Role for involuntary treatment in EDs: Few treatment
centers do involuntary treatment of ED.
- Involuntary treatment can involve guardianship for medical
- Guardianship is useful for medical treatment and admission to a
medical ward, for example, when a patient requires forcible tube
feeding for life-threatening starvation.
- Commitment or certification is required for involuntary
treatment in a psychiatric hospital.
- Commitment is sought by a psychiatrist and is a tool in cases
when the patient is dangerous to self or others and is gravely
- It is useful to commit a patient who is refusing care and has
not been sick for long. Often, commitment/certification is used as
a last resort, and the patient is too sick to truly recover.
- Pros and cons of involuntary treatment:
- Pro: No difference in weight restoration in voluntary vs.
involuntary treatment, and patients are often grateful after
- Cons: Involuntary tube feeding has unclear long-term outcomes.
- Some studies show poor outcomes for people who are treated
involuntarily, though this is likely because of their
Novel treatment options:
- Ketamine has been used in EDs. Concerns remain about the drug’s
addictive potential and inability to clearly change eating disorder
- Oxytocin: There are reduced cerebrospinal fluid levels of
oxytocin in AN, and oxytocin restores during recovery.
- Experimentally in rats, oxytocin may reduce the fear and social
phobias related to eating.
- Electroconvulsive therapy does not reduce ED symptoms such as
restricted eating and fear of fatness, but it can improve
- People with ED are often medically ill, so the patient must be
physically able to undergo treatment.
- Because of medical comorbidities, AN patients are more likely
to have complications like delirium.
- Transcranial magnetic stimulation: Dorsolateral prefrontal
cortex involved in self-regulatory control, inhibitory control, and
- Some studies show promising results of using this intervention
with ED and mild side effects like syncope and headache.
- Deep brain stimulation (DBS): Treatment targets the nucleus
accumbens and the subcallosal cingulate gyrus, which theoretically
alter balance between reward and cognitive inhibitory and control
systems that are related to pathological eating behaviors.
- DBS has strongest theoretical rationale in terms of
Eddy J. Recovery from anorexia nervosa and bulimia nervosa
at 22-year follow-up. Clin Psychiatry.
Sjostrand M et al. Ethical deliberations about involuntary
treatment: Interviews with Swedish psychiatrists. BMC Med
Geppert C. Futility in chronic anorexia nervosa: A concept
whose time has not yet come. Am J Bioethics. 2015.
Cushla M. Is resistance (n)ever futile? A response to “Futility
in chronic anorexia nervosa: A concept whose time has not yet
come,” by Cynthia Geppert.
Am J Bioethics. 2015 Jul 6. 15(7):53-4.
In part 2, Dr. Westmoreland will discuss harm reduction,
palliative care, and futility.