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Treatment - Anorexia Nervosa

Mark Dombeck, Ph.D. Updated: Nov 6th 2001

Anorexia Nervosa
Treatment

Table of Contents

Introduction
Psychotherapy
Hospitalization
Medications
Self-Help

Introduction

The treatment of this disorder is often difficult; some individuals are notoriously difficult to help. This is because of the disorder's insidious nature which wreaks havoc not only with the body, but just as seriously with the individual's negative self-perception. Usually starvation is not an immediate concern of most individuals who present with this disorder, but body weight and nutrition should be thoroughly evaluated at the onset of therapy. A complete medical examination is usually warranted to evaluate the patient's health and medical status. Underweight individuals often suffer from medical complications.

If a person who suffers from anorexia is in any danger to him or herself through lack of eating (e.g., starvation), immediate hospitalization should be carefully considered. Many individuals who suffer from this disorder see no problem with their body weight and will actually perceive themselves as being overweight. They may present to treatment, therefore as unwilling and uncooperative participants, brought in by family, friends, or another concerned professional.

All clinicians who treat an individual suffering from anorexia need to be cooperative and supportive of the patient's efforts throughout treatment. There is no one or easy way of gaining the client's cooperation in treatment, especially if they have been brought to treatment against their desires. While this can be one of the most difficult aspects of treatment with this individual, building a trusting and supportive relationship with him or her is likely the most important part of treatment.

Psychotherapy

Psychotherapy needs to focus on a number of issues, after a therapeutic, trusting relationship has been established. The most powerful issue is the obsession with body-image, which is also the most difficult to change. The client's preoccupation with body-image can make any clinician shake their heads in frustration; therapists must therefore carefully monitor counter-transference issues. These individuals can be an extreme challenging group to work with.

If the client is being seen in an inpatient facility or presents to an outpatient center in a severely emaciated state, basic nutritional needs must first be met. This is often done through an IV, because the individual will refuse to eat. This is certainly not an ideal way to start therapy or build a trusting relationship with the patient. The client may need immediate attention to ward off medical complications, yet restoring the body to a normal nutritional state may be the ultimate goal of therapy overall. Gains will be slow and progress may be uncertain. The individual may experience many relapses into anorexia before finally succeeding in therapy.

If the individual is not in immediate crisis or suffering from medical complications from the disorder, individual psychotherapy is usually a good starting basis of treatment. Cognitive-oriented therapies, focusing on issues of self-image and self-evaluation, are likely to be the most beneficial to the client. Distorted self-body images are most common amongst people who suffer from this disorder and should be the initial focus of treatment. The client should be instructed on how to recognize appropriate weight and body fat proportions of a normal body and relate that to theirs. Psychoeducational materials and approaches may be helpful in some cases.

Often negative self-image is created by specific traumatic events or memories within the individual's developmental stages of childhood. Parents may play an important role in helping to inadvertently nurture a negative self-image in the individual. These are appropriate and important issues in which to touch upon in therapy. Family therapy is therefore sometimes beneficial in uncovering the reinforcers the individual is receiving from significant others in their lives to remain thin. Family therapy can also be very helpful in educating the family about the child's disorder and how to ensure the patient's compliance with treatment recommendations. An individual's prognosis for recovery from an eating disorder is increased if the person does not binge or purge and they have only had the disorder for less than 6 months. A good support system is essential to quick recovery.

Group therapy is not only an appropriate modality, but often a chosen modality for its cost-savings as well as its powerful effects. In groups specifically devoted to issues of eating disorders, a patient can gain not only support for the gradual gains they accomplish, but also be confronted on issues more easily than in individual therapy.

Children and adolescents can also suffer from this disorder. Treatment for this population needs to emphasize and increase the positive reinforcements granted for each incremental weight gain. These should occur on a daily basis and different rewards should be given for different increments gained (e.g., a reward for 1/4 lb. should be different than a reward for a 1/2 lb.). By focusing on weight increase and not food intake, this technique will likely minimize distracting and useless arguments.

Hospitalization

Hospitalization of anybody for a mental disorder can often be a confusing and emotion-wrought decision. Family members or significant others may need to intervene in the patient's life to ensure they do not starve themselves to death. In these cases, hospitalization is not only necessary, but a prudent treatment intervention. Family members should be aware that individuals who suffer from anorexia nervosa will often resist treatment of any sort, especially hospitalization. It is important, therefore, to come to an agreement about the need for such a step and not be swayed by the patient's pleas for seeking alternative treatment options. Often these have already been tried to no success.

A behaviorally-oriented token economy often exists in psychiatric inpatient units specializing in eating disorders. This program rewards patients for eating regular meals and ensuring they do not purge afterwards. As the patient gains weight, additional hospital privileges may be granted. A specific target weight should be set as the treatment goal, upon which time the patient (ideally), should graduate from the hospital into an outpatient program consisting of individual therapy, group therapy, or simply a support group. Often this is not possible because of financial limitations. Treatment will usually then continue in an outpatient modality. If such a behavioral program is not implemented in the inpatient treatment facility the individual is in, treatment progress will likely be much slower and less steady.

Daily fluid intake and weight should be tracked. If the person vomits after meals, they should be watched for a few hours after each meal to ensure no vomiting occurs. The individual's diet should begin between 1,500 and 2,000 calories per day. This calorie intake can increase gradually as the patient makes treatment gains. The patient should have six equal feedings throughout the day, although this may not always be possible. Severely anorexic patients can be started on a liquid food supplement (e.g., Sustagen) or an IV, if necessary.

Inpatient programs (especially) should be careful not to overemphasize the importance of a person's weight, however. Weight is only the symptom in this disorder of poor body image and self-esteem problems. These primary difficulties should be the focus of any treatment approach for an eating disorder. Weight gain can be used as an objective measure as to treatment progress.

Medications

Some medications can be extremely helpful in treatment a person who suffers from anorexia nervosa. As always, the medication should be carefully monitored, especially since the patient may be vomiting, which may impact on the medication's effectiveness. A trusting and honest relationship must be established between the physician and the individual or mediation compliance will almost certainly become an issue.

Antidepressants (such as amitriptyline) are the usual drug treatment and may speed up the recovery process. Chlorpromazine may be beneficial for those individuals suffering from severe obsessions and increased anxiety and agitation.

Electroconvulsive therapy (ECT) is never an appropriate treatment option for a person suffering from an uncomplicated eating disorder.

Self-Help

Self-help methods for the treatment of this disorder are often overlooked by the medical profession because very few professionals are involved in them. Self-help support groups are an especially powerful and effective means of ensuring long-term treatment compliance and decrease the relapse rate. Individuals find they can bounce ideas off of one another, get objective feedback about body image, and just gain increased social support. Many support groups exist within communities throughout the world which are devoted to helping individuals with this disorder share their commons experiences and feelings.

References:
Internet Mental Health

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Discuss this issue below or in our forums.

Research evidence - - Apr 12th 2011

I am doing an A level in psychology and was wondering if anyone knows of any evidence relating to the effectiveness of token economy as a treatment for anorexia?

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