This case presents a patient with anorexia nervosa that was treated over the course of her four-year undergraduate career primarily in an outpatient setting. After two years of multidisciplinary treatment with a physician, a dietitian, a therapist and taking an SSRI, she decided to start risperidone. Although many studies have focused on olanzapine for weight gain, risperidone was chosen for its more favorable side effect profile and the significant decreased cost to the patient. The patient’s lab work remained within normal limits after initiating treatment, suggesting a low dose atypical antipsychotic could provide the benefit of gradual weight gain without metabolic consequences. Reduced cost to the patient may not only increase compliance and initial willingness to try the medication, but also justifies the use of risperidone instead of olanzapine as a long-term therapy to maintain weight gain and reach a recovery phase.
Near the end of her treatment, after resumption of menses, the patient was queried as to why she felt the risperidone was helpful in her recovery. The patient felt that she had a significant improvement in rigidity during meal times after starting the risperidone. Despite having similar motivation to improve her nutrition in the past, the rigidity was a barrier that she was not able to overcome until the reperidone was started. Also, it is well known that weight gain is a side effect of risperidone therapy. While her metabolic labs were normal and stable during her treatment, the possibility that weight gain as a side effect of risperidone contributed to her resumption of menses is another conceivable factor in her recovery. Therefore, a combination of factors related to the risperidone likely played a role in the patient’s recovery.
This case is unique because the patient had good insight and was motivated to gain weight, resulting in strict compliance with her medical treatment. The patient was highly motivated to attend college and had strong support from her parents and friends relative to other patients treated in the eating disorders clinic. However, these impressions are subjective. Therefore, one limitation to this report is that personal events throughout this patient’s undergraduate experience that may have influenced her improved health are not quantifiable. Previous studies focused on treating AN tend to be limited due to the ego-syntonic quality of AN and the refusal to start or maintain treatment for fear of weight gain as a medication side effect (Balestrieri et al. 2013). For this reason, replicating the compliance and success demonstrated in this case report might be difficult in a patient unmotivated to gain weight. For patients noncompliant with oral medication, risperidone long-acting injection may be another beneficial alternative (Umehara et al. 2014). Not only was this patient able to gain weight with risperidone, she experienced decreased rigidity around meal times and was able to decrease her SSRI dose for anxiety. Previously published studies, with one exception (Hagman et al. 2011), have not treated AN with concomitant SSRI and atypical antipsychotics, and this is the only report to our knowledge of decreasing the SSRI dose during the treatment period. Resumption of menses after one year on risperidone was another measure of improvement that has been mentioned only one time previously in the literature (Newman-Toker 2000). The patient had experienced secondary amenorrhea for 3 years and 8 months before the return of her menses. This case also represents the longest published treatment with an atypical antipsychotic, 17 months, in addition to being completely in an outpatient setting. Therefore, risperidone may become a feasible and effective outpatient option for patients with AN. She experienced no side effects from her medications, and when asked which therapy helped her the most, she contributed her successful weight gain to risperidone.