Skip to main content
Log in

Antipsychotic Agents in the Treatment of Anorexia Nervosa: Neuropsychopharmacologic Rationale and Evidence from Controlled Trials

  • Eating Disorders (E Attia, Section Editor)
  • Published:
Current Psychiatry Reports Aims and scope Submit manuscript

Abstract

The search for an effective psychopharmacologic strategy in the treatment of anorexia nervosa (AN) has been elusive for decades and has run the gamut from reserpine to typical antipsychotics, to lithium, to tetrahydrocannabinol, to growth hormone, to anticonvulsants, to antidepressants, to atypical antipsychotics. Only recently has there arisen a potential “diamond in the rough” in the form of the atypical antipsychotic agent, olanzapine, which, in four randomized clinical trials, has shown superiority to placebo (two studies), chlorpromazine (one study), and aripiprazole (one study) in terms of weight gain and/or reduction in obsessional symptoms. The pharmacologic profile of olanzapine and other antipsychotic medications is discussed in light of the known pathophysiology of AN involving serotonin and dopamine systems, as well as brain-derived neurotrophic factor.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Bruch H. Eating disorders: Obesity, anorexia nervosa, and the person within. Houston: Basic Books; 1973.

    Google Scholar 

  2. Steinglass JE, Eisen JL, Attia E, et al. Is anorexia nervosa a delusional disorder? An assessment of eating beliefs in anorexia nervosa. J Psychiatr Prac. 2007;13:65–71.

    Article  Google Scholar 

  3. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-IV). 4th ed. Washington: American Psychiatric Association; 1994.

    Google Scholar 

  4. Maher AR, Maglione M, Bagley S, et al. Efficacy and comparative effectiveness of atypical antipsychotic medications for off-label uses in adults: a systematic review and meta-analysis. JAMA. 2011;306:1359–69.

    Article  PubMed  CAS  Google Scholar 

  5. McElroy SL, Kotwal R, Keck Jr PE, Akiskal HS. Comorbidity of bipolar and eating disorders: distinct or related disorders with shared dysregulations? J Affect Dis. 2005;86:107–27.

    Article  PubMed  Google Scholar 

  6. McElroy SL, Kotwal R, Keck Jr PE. Comorbidity of eating disorders with bipolar disorder and treatment implications. Bipolar Dis. 2006;8:686–95.

    Article  CAS  Google Scholar 

  7. Wildes JE, Marcus MD, Fagiolini A. Prevalence and correlates of eating disorder co-morbidity in patients with bipolar disorder. Psychiatry Res. 2008;161:51–8.

    Article  PubMed  Google Scholar 

  8. Wang TS, Chou YH, Shiah IS. Combined treatment of olanzapine and mirtazapine in anorexia nervosa associated with major depression. Prog Neuro-Psychopharm Biol Psychiatry. 2006;30:306–9.

    Article  CAS  Google Scholar 

  9. Attia E, Mayer L, Killory E. Medication response in the treatment of patients with anorexia nervosa. J Psychiatr Pract. 2001;7:157–62.

    Article  PubMed  CAS  Google Scholar 

  10. Walsh BT, Kaplan AS, Attia E, et al. Fluoxetine after weight restoration in anorexia nervosa: A randomized controlled trial. JAMA. 2006;295:2605–12.

    Article  PubMed  CAS  Google Scholar 

  11. Brewerton TD. Drug therapy for patients with eating disorders. Psychiatric Times. 2004;21:59–68.

    Google Scholar 

  12. Brewerton TD. Toward a unified theory of serotonin dysregulation in eating and related disorders. Psychoneuroendocrinol. 1995;20:561–90.

    Article  CAS  Google Scholar 

  13. Brewerton TD. Transmitter systems in the eating disorders. In: D’aemon (ed) Textbook of biological psychiatry. 2002.

  14. Brewerton TD, Steiger H. Neurotransmitter dysregulation in anorexia nervosa, bulimia nervosa and binge eating disorder. In: Brewerton TD, editor. Clinical handbook of eating disorders: An integrated approach. London: Marcel Dekker; 2004.

    Google Scholar 

  15. Brewerton TD, Frampton I, Lask B. The neurobiology of anorexia nervosa. US Psychiatry. 2009;2:57–64.

    Google Scholar 

  16. Kaye WH. Persistent alterations in behavior and serotonin activity after recovery from anorexia and bulimia nervosa. Ann N Y Acad Sci. 1997;817:162–78.

    Article  PubMed  CAS  Google Scholar 

  17. Kaye WH, Gwirtsman HE, George DT, Ebert MH. Altered serotonin activity in anorexia nervosa after long-term weight restoration. Arch Gen Psychiatry. 1991;48:556–62.

    Article  PubMed  CAS  Google Scholar 

  18. Kaye W, Strober M, Stein D, Gendall K. New directions in treatment research of anorexia and bulimia nervosa. Biol Psychiatry. 1999;45:1285–92.

    Article  PubMed  CAS  Google Scholar 

  19. Kaye W. Neurobiology of anorexia and bulimia nervosa. Physiol Behav. 2008;94:121–35.

    Article  PubMed  CAS  Google Scholar 

  20. Bailer UF, Price JC, Meltzer CC, et al. Altered 5-HT(2A) receptor binding after recovery from bulimia-type anorexia nervosa: relationships to harm avoidance and drive for thinness. Neuropsychopharmacol. 2004;29:1143–55.

    Article  CAS  Google Scholar 

  21. Bailer UF, Frank GK, Henry SE, Price JC, Meltzer CC, Mathis CA, Wagner A, Thornton L, Hoge J, Ziolko SK, Becker CR, McConaha CW, Kaye WH. Exaggerated 5-HT1A but normal 5-HT2A receptor activity in individuals ill with anorexia nervosa. Biol Psychiatry. 2007;61:1090–9.

    Article  PubMed  CAS  Google Scholar 

  22. Galusca B, Costes N, Zito NG, et al. Organic background of restrictive-type anorexia nervosa suggested by increased serotonin 1A receptor binding in right frontotemporal cortex of both lean and recovered patients: [18 F]MPPF PET scan study. Biol Psychiatry. 2008;64:1009–13.

    Article  PubMed  CAS  Google Scholar 

  23. Audenaert K, Van Laere K, Dumont F, et al. Decreased 5-HT2a receptor binding in patients with anorexia nervosa. J Nuclear Med. 2003;44:163–9.

    CAS  Google Scholar 

  24. Goethals I, Vervaet M, Audenaert K, et al. Differences of cortical 5-HT2A receptor binding index with SPECT in subtypes of anorexia nervosa: relationship with personality traits? J Psychiatr Res. 2007;41:455–8.

    Article  PubMed  Google Scholar 

  25. Bailer UF, Frank GK, Henry SE, Price JC, Meltzer CC, Becker CR, Ziolko SK, Mathis CA, Wagner A, Barbarich-Marsteller NC, Putnam K, Kaye WH. Serotonin transporter binding after recovery from eating disorders. Psychopharmacol. 2007;195:315–24.

    Article  CAS  Google Scholar 

  26. Ehrlich S, Franke L, Schott R, et al. Platelet monoamine oxidase activity in under weight and weight-recovered females with anorexia nervosa. Pharmacopsychiatry. 2008;41:226–31.

    Article  PubMed  CAS  Google Scholar 

  27. Gorwood P, Kipman A, Foulon C. The human genetics of anorexia nervosa. Eur J Pharmacol. 2003;480:163–70.

    Article  PubMed  CAS  Google Scholar 

  28. Rybakowski F, Slopien A, Dmitrzak-Weglarz M, et al. The 5-HT2A–1438 A/G and 5-HTTLPR polymorphisms and personality dimensions in adolescent anorexia nervosa: association study. Neuropsychobiology. 2006;53:33–9.

    Article  PubMed  CAS  Google Scholar 

  29. • Kiezebrink K, Mann ET, Bujac SR, Stubbins MJ, Campbell DA, Blundell JE. Evidence of complex involvement of serotonergic genes with restrictive and binge purge subtypes of anorexia nervosa. World J Biol Psychiatry. 2010;11:824–33. This recent genetic study showed a substantial and complex inter-relationship between several serotoninergic genes and AN. HTR2A was associated with both AN subtypes, while genes encoding HTR1D and HTR1B were associated with RAN and the gene encoding HTR2C was associated with BPAN. This study will help to guide future genetic research and also gives support for the use of atypical antipsychotics, such as olanzapine.

    Article  PubMed  Google Scholar 

  30. Bergen AW, van den Bree MB, Yeager M, et al. Candidate genes for anorexia nervosa in the 1p33-36 linkage region: serotonin 1D and delta opioid receptor loci exhibit significant association to anorexia nervosa. Mol Psychiatry. 2003;8:397–406.

    Article  PubMed  CAS  Google Scholar 

  31. Hu X, Giotakis O, Li T, et al. Association of the 5-HT2c gene with susceptibility and minimum body mass index in anorexia nervosa. Neuroreport. 2003;14:781–3.

    Article  PubMed  CAS  Google Scholar 

  32. Hammer C, Kapeller J, Endele M, et al. Functional variants of the serotonin receptor type 3A and B gene are associated with eating disorders. Pharmacogenet Genom. 2009;19:790–9.

    Article  CAS  Google Scholar 

  33. Martaskova D, Slachtova L, Kemlink D, et al. Polymorphisms in serotonin-related genes in anorexia nervosa. The first study in Czech population and metaanalyses with previously performed studies. Folia Biol. 2009;55:192–7.

    CAS  Google Scholar 

  34. Brown KM, Bujac SR, Mann ET, et al. Further evidence of association of OPRD1 & HTR1D polymorphisms with susceptibility to anorexia nervosa. Biol Psychiatry. 2007;61:367–73.

    Article  PubMed  CAS  Google Scholar 

  35. Hillebrand JJ, van Elburg AA, Kas MJ, van Engeland H, Adan RA. Olanzapine reduces physical activity in rats exposed to activity-based anorexia: possible implications for treatment of anorexia nervosa? Biol Psychiatry. 2005;58:651–7.

    Article  PubMed  CAS  Google Scholar 

  36. Verhagen LA, Luijendijk MC, Hillebrand JJ, Adan RA. Dopamine antagonism inhibits anorectic behavior in an animal model for anorexia nervosa. Eur Neuropsychopharmacol. 2009;19:153–60.

    Article  PubMed  CAS  Google Scholar 

  37. Wagner A, Aizenstein H, Venkatraman VK, et al. Altered reward processing in women recovered from anorexia nervosa. Am J Psychiatry. 2007;164:1842–9.

    Article  PubMed  Google Scholar 

  38. Bachner-Melman R, Lerer E, Zohar AH, et al. Anorexia nervosa, perfectionism, and dopamine D4 receptor (DRD4). Am J Med Genetics. 2007;144B:748–56.

    Article  CAS  Google Scholar 

  39. Frank GK, Bailer UF, Henry SE, et al. Increased dopamine D2/D3 receptor binding after recovery from anorexia nervosa measured by positron emission tomography and [11c]raclopride. Biol Psychiatry. 2005;58:908–12.

    Article  PubMed  CAS  Google Scholar 

  40. Frieling H, Romer KD, Scholz S, et al. Epigenetic dysregulation of dopaminergic genes in eating disorders. Int J Eat Disord. 2010;43:577–83.

    Article  PubMed  Google Scholar 

  41. • Brandys MK, Kas MJ, van Elburg AA. A meta-analysis of circulating BDNF concentrations in anorexia nervosa. World J Biol Psychiatry. 2011;12:444–54. This study suggests that BDNF is not only an important indicator of illness and recovery but may also be a target for drug action in the treatment of AN. It is already known that atypical antipsychotics, especially olanzapine, increase BDNF levels..

    Article  PubMed  Google Scholar 

  42. Ehrlich S, Salbach-Andrae H, Eckart S, et al. Serum brain-derived neurotrophic factor and peripheral indicators of the serotonin system in underweight and weight-recovered adolescent girls and women with anorexia nervosa. J Psych Neurosci. 2009;34:323–9.

    Google Scholar 

  43. Mercader JM, Fernandez-Aranda F, Gratacos M, et al. Blood levels of brain-derived neurotrophic factor correlate with several psychopathological symptoms in anorexia nervosa patients. Neuropsychobiology. 2007;56:185–90.

    Article  PubMed  CAS  Google Scholar 

  44. Monteleone P, Maj M. Genetic susceptibility to eating disorders: associated polymorphisms and pharmacogenetic suggestions. Pharmacogenomics. 2008;9:1487–520.

    Article  PubMed  CAS  Google Scholar 

  45. Stahl SM. Describing an atypical antipsychotic: Receptor binding and its role in pathophysiology. J Clin Psychiatry. 2003;5 Suppl 3:9–13.

    Google Scholar 

  46. Rizos EN, Papadopoulou A, Laskos E, et al. Reduced serum BDNF levels in patients with chronic schizophrenic disorder in relapse, who were treated with typical or atypical antipsychotics. World J Biol Psychiatry. 2010;11:251–5.

    Article  PubMed  Google Scholar 

  47. Brambilla F, Garcia CS, Fassino S, et al. Olanzapine therapy in anorexia nervosa: psychological effects. Int Clin Psychopharmacol. 2007;22:197–204.

    Article  PubMed  Google Scholar 

  48. •• Bissada H, Tasca GA, Barber AM, Bradwejn J. Olanzapine in the treatment of low body weight and obsessive thinking in women with anorexia nervosa: a randomized, double-blind, placebo-controlled trial. Am J Psychiatry. 2008;165:1281–8. This is a very important randomized, placebo-controlled study that demonstrated olanzapine’s ability to promote faster weight gain and alleviate obsessive symptoms in adult patients with AN who were receiving concurrent day treatment.

    Article  PubMed  Google Scholar 

  49. •• Attia E, Kaplan AS, Walsh BT, et al. Olanzapine versus placebo for out-patients with anorexia nervosa. Psychol Med. 2011;41:2177–82. This is a recent breakthrough study which showed that olanzapine significantly facilitates weight recovery in adult outpatients with AN in comparison to placebo. This was despite the absence of any adjunctive psychotherapy or behavior therapy during the trial.

    Article  PubMed  CAS  Google Scholar 

  50. Mondraty N, Birmingham CL, Touyz S, et al. Randomized controlled trial of olanzapine in the treatment of cognitions in anorexia nervosa. Australas Psychiatry. 2005;13:72–5.

    PubMed  Google Scholar 

  51. Attia E, Kaplan AS, Schroeder L, Federici A. Atypical antipsychotic medication for patients with anorexia nervosa. Presented at the Annual Meeting of the Eating Disorders Research Society, Toronto, Canada, 2005.

  52. Vandereycken W, Pierloot R. Pimozide combined with behavior therapy in the short-term treatment of anorexia nervosa. A double-blind placebo-controlled cross-over study. Acta Psychiatr Scand. 1982;66:445–50.

    Article  PubMed  CAS  Google Scholar 

  53. Vandereycken W. Neuroleptics in the short-term treatment of anorexia nervosa. A double-blind placebo-controlled study with sulpiride. Br J Psychiatry. 1984;144:288–92.

    Article  PubMed  CAS  Google Scholar 

  54. • Hagman J, Gralla J, Sigel E, et al. A double-blind, placebo-controlled study of risperidone for the treatment of adolescents and young adults with anorexia nervosa: a pilot study. J Am Acad Child Adol Psych. 2011;50:915–24. This is the only randomized, placebo-controlled study that has examined the role of risperidone in the treatment of AN—in this case, adolescent inpatients being treated in a specialized eating disorder service. Although there was no difference in weight gain, those receiving risperidone demonstrated significant improvements in interpersonal distrust compared with placebo.

    Article  Google Scholar 

  55. • Kafantaris V, Leigh E, Hertz S, et al. A placebo-controlled pilot study of adjunctive olanzapine for adolescents with anorexia nervosa. J Child Adol Psychopharmacol. 2011;21:207–12. This recent randomized, placebo-controlled study examined the role of olanzapine in a group of adolescents being treated in a specialty eating disorder service. There was no statistically significant benefit of olanzapine for weight or psychological symptoms. Again, we see that olanzapine seems to primarily benefit individuals who are not receiving concurrent intensive treatment.

    Article  CAS  Google Scholar 

Download references

Disclosure

No potential conflicts of interest relevant to this article were reported.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Timothy D. Brewerton.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Brewerton, T.D. Antipsychotic Agents in the Treatment of Anorexia Nervosa: Neuropsychopharmacologic Rationale and Evidence from Controlled Trials. Curr Psychiatry Rep 14, 398–405 (2012). https://doi.org/10.1007/s11920-012-0287-6

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11920-012-0287-6

Keywords

Navigation