Eating Disorders

Introduction to Compulsive Eating

• Compulsive eating disorder often coexists with other compulsive disorders, such as shopping compulsion, with emotional factors exacerbating both conditions, as suggested by the American Heart Association and the American College of Cardiology 1

Treatment and Management

• A weight loss of 5-10% can significantly improve metabolic and hormonal outcomes in individuals with compulsive eating disorder, as recommended by the American Heart Association 1
• Treatment-resistant OCD is defined as an inadequate response to at least one adequate trial of an SSRI or clomipramine, with an adequate trial consisting of 8-12 weeks at maximum tolerated dose, and maximum recommended doses for OCD are higher than for depression, such as fluoxetine 20-80 mg/day, sertraline 50-200 mg/day, as reported by the International College of Obsessive-Compulsive Spectrum Disorders 2
• The following medication dosages are recommended for OCD treatment:

• About one-third of patients show a clinically meaningful response to antipsychotic augmentation of SSRIs, such as risperidone or aripiprazole, but requires careful monitoring for adverse effects, including weight gain, metabolic dysregulation, and extrapyramidal symptoms, as reported by the International College of Obsessive-Compulsive Spectrum Disorders 2
• N-acetylcysteine and memantine have the strongest evidence base for glutamatergic agent augmentation, with several randomized controlled trials demonstrating superiority to placebo, as reported by the International College of Obsessive-Compulsive Spectrum Disorders 2
• Clomipramine may be effective when SSRIs fail, though it has more side effects, and clomipramine + SSRI combination can be effective but requires careful monitoring due to the risk of severe adverse events, including seizures, heart arrhythmia, and serotonin syndrome, as warned by the International College of Obsessive-Compulsive Spectrum Disorders 2
• Cognitive Behavioral Therapy (CBT) with Exposure and Response Prevention (ERP) is the most evidence-based psychotherapy for OCD, with larger effect sizes than medication alone, and can be delivered in 10-20 sessions, either in-person or via telehealth, as recommended by the American Psychological Association and the American Academy of Family Physicians 2, 3
• Deep repetitive Transcranial Magnetic Stimulation (rTMS) is FDA-approved for OCD, and Deep Brain Stimulation (DBS) is reserved for very intractable cases, with approximately 30-50% of severe refractory OCD patients responding to DBS, as reported by the International College of Obsessive-Compulsive Spectrum Disorders 2
• A treatment algorithm for treatment-resistant OCD includes switching to another SSRI or clomipramine, adding CBT with ERP to medication therapy, considering augmentation strategies, and considering intensive outpatient or residential treatment for severe cases, as recommended by the International College of Obsessive-Compulsive Spectrum Disorders 2
• Patients should be monitored for suicidal ideation, particularly in the first months of treatment and following dose adjustments, as well as behavioral activation/agitation, hypomania, and mania, as warned by the International College of Obsessive-Compulsive Spectrum Disorders 2
• Implementing regular physical activity and addressing loneliness and social isolation are suggested by The Lancet Healthy Longevity as important components of comprehensive treatment 4

Treatment Guidelines

• The American Psychiatric Association recommends verifying true treatment resistance by confirming adequate dose and duration, assessing medication adherence, and ruling out comorbidities complicating treatment 2
• The International College of Obsessive-Compulsive Spectrum Disorders suggests ensuring maximum recommended or tolerated dose has been reached and verifying adequate duration (8-12 weeks at maximum dose) before considering treatment-resistant 2
• The American Psychological Association and the International OCD Foundation recommend CBT with ERP as the most effective psychotherapy for OCD, with larger effect sizes than pharmacological therapy, and can be used alone or in combination with medication 2