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Treatments for Anorexia Nervosa

The following treatment guidelines are meant as a reference tool only, and are not intended as treatment advice or to replace the clinical decision-making process of psychiatrists or other health professionals who administer these treatments. In clinical practice there are often good reasons why treatment approaches differ from what is described here.

Treatment Setting

The first issue to determine when treating someone with Anorexia Nervosa is the extent of their weight loss and malnutrition and their general medical status. Anorexia Nervosa has the highest mortality rate of all psychiatric conditions [ref], which is due in large part to the medical complications that can result from being in a state of starvation or of engaging in excessive purging behaviors. If any of the following medical abnormalities are detected, the individual would need to be hospitalized, involuntarily if necessary, with proper medical monitoring, and possibly with complete bed rest and nasogastic tube feeding [ref]:

    • Weight < 75% of normal or Body Mass Index <13
    • Heart rate < 40 bpm
    • Blood pressure < 90/60 mm Hg
    • Glucose < 60 mg/dL
    • Potassium < 3 meq/L
    • Electrolyte imbalance
    • Temperature < 97.0°F
    • Dehydration
    • Hepatic, renal, or cardiovascular organ compromise requiring acute treatment
    • Poorly controlled Diabetes Mellitus

In general, it is preferable that treatment for Anorexia Nervosa be provided by a specialized Eating Disorders treatment program that offers a combination of the various indicated treatment modalities (see below) delivered by a team of experienced clinicians. These are intensive treatment programs that may include hospitalization or partial hospitalization (ie. full-day outpatient care), often for several weeks or months.

Full hospitalization is recommended for individuals who are resistant to the idea of regaining their normal weight and need to be supervised at and after meals and even in the bathrooms to make sure that they are not restricting their food intake or purging. Having other serious co-occuring psychiatric conditions, including Substance Abuse or suicidal tendencies, would also be important reasons to consider inpatient treatment.

Weight Restoration

Whether in an inpatient or full-day outpatient care setting, the first goal of treatment is to achieve restoration of normal body weight.

From a medical viewpoint, this should be done in a controlled and monitored fashion, especially for severely underweight individuals, because refeeding that is done too rapidly can lead to its own medical complications, including hypophosphatemia, which can cause cardiac arrhythmias. Input from a dietician is usually required to determine the appropriate refeeding schedule. Regular measurements of serum electrolytes and monitoring for signs of fluid overload are indicated.

From a psychological point of view, weight restoration seems to be achieved most effectively by using a behavioral approach [ref, ref]. Weight targets are determined in advance and patients are given various rewards for meeting each of the targets. Consequences are used - such as the removal of privileges in the treatment unit or forced bed rest - when targets are not met or the patient continues to engage in food-restricting and binge-eating and purging behaviors.

Other forms of psychotherapy (see below) have been found to be minimally effective during the weight restoration phase, and are thus generally not used until weight has been successfully restored [ref, ref].

Due to the fragile medical condition of individuals who are severely underweight, the use of psychiatric medications is generally avoided until normal weight has been restored. SSRIs, in particular, have been shown not to be effective during this stage of treatment [ref]. There is preliminary evidence that Olanzapine can help to restore patients' weight and also to reduce depressive, anxious and core Eating Disorder symptoms during this first phase of treatment [ref, ref], but until more rigorous studies confirm these findings, this treatment should be reserved for cases where the patient remains very resistant to gaining weight [ref].

Weight Maintenance and Relapse Prevention

Once normal weight has been restored, the goal of treatment becomes to address the individual's maladaptive core beliefs, attitudes and preoccupations that have contributed to their Eating Disorder so that proper eating habits can be maintained, relapses prevented, and the individual's general quality of life improved. The main treatment modalities currently available to achieve these goals are individual and family therapy.

Individual psychotherapy has a moderate amount of evidence to suggest that it is effective [ref]. Cognitive Behavioral Therapy, Psychodynamic Therapy and Interpersonal Therapy are all acceptable options. Usually the psychotherapy needs to be offered for at least one year in order to address the various underlying psychological issues [ref].

For children and adolescents with Anorexia Nervosa, Family Therapy has also be shown to be effective [ref, ref, ref], and there is some evidence that this may as effective, if not more so, than individual psychotherapy [ref]. The question of whether it is best to offer both individual and Family Therapy to all people with Anorexia Nervosa has not been well researched, though some authorities recommend that it is best for the immediate family to be involved in some form of therapy, even if the adolescent patient is being seen separately [ref].

Empirical research to support the use of Group Therapy for Anorexia Nervosa is very sparse [ref, ref], with some conflicting results [ref]. Still, this method is used commonly in many treatment programs.

Regarding the use of medications, there is no evidence to support the regular use of any psychiatric medications to help individuals with Anorexia Nervosa maintain a healthy weight level or to prevent relapse. Although one smaller study suggests that Fluoxetine may be helpful in this regard [ref], another larger and more recent study refuted this finding [ref].

 

Associated Conditions (Comorbidity)

Bulimia Nervosa