A 20-year-old woman is assessed at the insistence of her parents, who are worried about her weight loss and changes in behavior. The patient returned home from college having lost over 13.6 kg (30 lb) during the academic year. She is an excellent student and is highly active in leadership roles and public speaking. She insists that "appearance is everything" and is concerned that she looks "fat." The patient is now an avid cook and frequently bakes desserts for the family but consumes only small amounts of fruits and vegetables daily. She also runs at least 2 hours a day when not working as an assistant in a dentist's office. Her parents are worried and say, "She is too focused on her appearance and looks too thin." Meanwhile, the patient says she just wants "everyone to stop worrying about me." Her last menstrual period was 4 months ago.
Vital signs are within normal limits. BMI is 17.5 kg/m².
The patient is referred for nutritional rehabilitation and psychotherapy. Despite these interventions, she returns for a 2-month follow-up having lost an additional 4.5 kg (10 lb) .
Which of the following medications is most appropriate for this patient's condition?

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11ec193a_98ab_dbb8_853d_21d1ca09f748_MD0002_00 This patient's refusal to maintain an appropriate body weight, anxiety about gaining weight, and distorted views of body weight and shape make anorexia nervosa the mostly likely diagnosis. The mainstay of treatment for anorexia nervosa is nutritional rehabilitation plus psychotherapy (eg, cognitive-behavioral therapy, psychodynamic psychotherapy, motivational interviewing, family therapy). Pharmacotherapy can be considered as an adjunct in patients who do not gain weight despite nutritional rehabilitation and psychotherapy. Evidence from research trials supports the use of the 2nd-generation antipsychotic olanzapine to accelerate weight gain. Other psychotropic drugs, including antidepressants and benzodiazepines, have not been found to be beneficial. When using olanzapine for anorexia, it is important to begin with a low dose and monitor carefully as these patients are at increased risk of side effects due to their low weight (eg, cardiac conduction delays, toxicity from volume depletion). (Choice A) There is insufficient evidence that other 2nd-generation antipsychotics (eg, aripiprazole) facilitate weight gain in anorexia nervosa. (Choice B) Bupropion is contraindicated in patients with eating disorders due to seizure risk. (Choices C and E) Selective serotonin reuptake inhibitor antidepressants have demonstrated efficacy in bulimia nervosa, with the best evidence for fluoxetine. However, antidepressants have not been shown to be beneficial in anorexia nervosa. Educational objective: The mainstay of treatment for anorexia nervosa is nutritional rehabilitation plus psychotherapy. In treatment-resistant cases, olanzapine can be used as an adjunct to help accelerate weight gain. __________ References: Olanzapine versus placebo for out-patients with anorexia nervosa. (http://www.ncbi.nlm.nih.gov/pubmed/21426603) Pharmacotherapy of eating disorders. (http://www.ncbi.nlm.nih.gov/pubmed/28806268)

A 20-Year-Old Woman Is Assessed at the Insistence of Her