Feeding and Eating Disorders

A 17-year-old with restricting-type anorexia nervosa is acutely depressed and underweight at the same time. The question isn't whether her mood deserves treatment — it's whether an SSRI can even work on a brain this malnourished, or whether starting one now just adds a drug with no real chance of helping.

An outpatient with anorexia nervosa is doing everything asked of her and still not gaining weight, because the obsessional anxiety around food consumes more of the session than the food itself. Olanzapine has real randomized evidence in her population — for the weight, not for the anxiety — which means the effect she would most want is the one the trial specifically failed to find, and the effect it does produce is the one she fears most.

A newly weight-restored college student is heading back into the exact environment that fed her illness, and everyone wants to give her every advantage available — including a drug that an earlier, smaller trial suggested might help, and a later, larger, better trial found does nothing at all.

Fluoxetine is the only medication actually approved for bulimia nervosa. This patient is already stable on sertraline for a pre-existing depression. Whether the approval reflects real superiority or just which drug happened to get the pivotal trial is the question the team has to answer before touching a regimen that's currently working.

Bupropion carries a flat contraindication in bulimia nervosa, current or past, because of a seizure signal found decades ago in actively purging patients. This man has been in confirmed remission for eight months. Whether the original mechanism still applies to him — or whether the label was never really about him in the first place — is the whole disagreement.

Lisdexamfetamine is the only medication approved specifically for binge eating disorder, and it's a Schedule II stimulant. This patient's binges are real and frequent, and so is a stimulant misuse history from fifteen years ago that she has been honest about the entire time. Whether that history should close the door on the one approved option is genuinely contested.

Semaglutide is approved for his diabetes and his weight, but not for the binge eating disorder actually driving both. Early evidence suggests it might help the bingeing directly, not just the weight — but 'might' is doing a lot of work in a population where appetite suppression itself is not automatically a safe thing to induce.

This eight-year-old isn't restricting because of any fear of weight gain — his aversion is sensory, and it predates any concept of dieting he could even have. Whether an appetite-stimulating antidepressant belongs anywhere near a problem this specific, on evidence this thin, is what's actually being decided.

Everyone in the room agrees thiamine goes in before or with the first calorie, no exceptions. What they don't agree on is whether the traditional 'start low, go slow' caloric ramp is actually the safer path, or whether it's the more conservative-sounding choice that leaves a starving teenager malnourished for longer than a newer, faster protocol would.

The bupropion-in-bulimia seizure warning traces to purging, not to eating disorders as a category. This patient has binge eating disorder and has never purged in her life. Whether the label's actual wording — which doesn't distinguish the two — should still govern her case is a real test of whether a mechanism-based argument is allowed to override a diagnosis-based label.