AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Background

Richard Morton first described anorexia nervosa more than 300 years ago, in 1689, as a condition of "a Nervous Consumption" caused by "sadness, and anxious Cares." In 1873, 2 prominent physicians separately described anorexia nervosa; Charles Laségue described it as "a hysteria linked to hypochondriasis," and Sir William W. Gull described it as "a perversion of the ego." This was the same year the disorder received its current name. In the first half of the 20th century, a variety of views of the disorder emerged. Pierre Janet considered anorexia to be a purely psychological disorder. Morris Simmonds proposed that pituitary insufficiency led to weight loss in some patients. Berkman viewed physiological disturbances as secondary to the psychological etiology of the disturbance.

Additional formulations of and insights into anorexia were developed in recent times by several modern pioneers. Bruch viewed self-starvation as a representation of struggle for autonomy, competence, control, and self-respect. Failure of the mother to recognize and confirm the child's independent needs was purported to produce inner confusion in 3 overlapping areas. These areas include a tendency to overestimate body size; an inability to correctly identify internal sensations such as hunger, satiety, affective states, and sexual feelings; and a sense of ineffectiveness characterized by feelings of loss of control.

Mara Selvini Palazzoli developed a view similar to Bruch's, but Palazzoli postulates that patients with anorexia experience the body as "the maternal object, from which the ego wishes to separate itself at all costs."

Crisp proposed a developmental model, with the psychopathology of anorexia stemming from biological and psychological experiences surrounding the achievement of adult weight. Conflicted about attaining psychological maturity, patients with anorexia use dieting and subsequent starvation as a means to regress back to prepubescent size, hormonal status, and life experience.

Although anorexia historically has been defined by self-imposed starvation, binge eating has been reported as part of the clinical picture over the years. DaCosta and Halmi reviewed 14 studies in which they divided patients with anorexia nervosa into bulimic and nonbulimic subtypes. Patients with bulimia and anorexia nervosa were found to report greater impulsivity, social involvement, sexual activity, family dysfunction, depression, and conspicuous emotional disturbance in general.

Purging behaviors associated with binge eating (ie, induced vomiting and/or laxative use), rather than binge eating, have been viewed to be better indicators for subclassifying anorexia nervosa. Garner et al found that the psychopathology of patients with anorexia who engage in purging behavior is distinguishable from the psychopathology of patients with anorexia who do not purge.

In an effort to describe the "essence" of anorexia nervosa, Sten Theander outlines the common traits of the disorder. These traits include "the marked preponderance of females and young people among the patients; food refusal; the extreme, often life-threatening emaciation, but also the tendency to recovery, and the denial of illness."

Gerald Russell contends the disorder has changed over the last 30-50 years or more. Specifically, Russell notes that the psychological content of anorexia nervosa has shifted to a dread of fatness, which is congruent with the high value society affords thinness in women. Russell also notes that the incidence of the disorder has risen since the late 1950s, likely due to adverse sociocultural factors.

One of the great challenges of the day, and of the future, is how to effectively treat this complex multidimensional psychiatric disorder in the era of managed care.

Pathophysiology

Definition of problem

Anorexia nervosa is characterized by the individual's refusal to maintain minimally normal body weight, an intense fear of gaining weight, and significant disturbance in the perception of the shape or size of the body. Additionally, postmenarchal females with this disorder are amenorrheic (ie, exhibit the absence of at least 3 consecutive menstrual cycles).

Once the diagnosis has been made, mutually exclusive subtypes can be used to specify the presence or absence of binge-eating/purging behavior. Patients with the restricting type accomplish weight loss primarily through dieting, fasting, or excessive exercise. Regular binge-eating or purging does not occur. Patients with the binge-eating/purging type regularly engage in binge-eating or purging behavior (eg, self-induced vomiting, or misuse of laxatives, diuretics, or enemas). Most individuals in this category engage in these behaviors at least weekly.

Individuals with anorexia who binge or purge have been found to be more likely than those with the restricting type to show problems with impulse control (eg, substance use disorder, emotional lability, sexual activity), have had the illness longer, and are somewhat heavier. Patients with the restrictive type are more likely to be more obsessional, more socially awkward, and more isolated than those with the binge-eating/purging type.

Associated features and disorders may include depressed mood, social withdrawal, irritability, insomnia, and diminished interest in sex. Obsessive-compulsive features related to and unrelated to food also may be present. Additional features may include concerns about eating in public, feelings of ineffectiveness, a strong need to control one's environment, inflexible thinking, limited social spontaneity, and overly restrained initiative and emotional expression.

The stability of the 3 DSM-IV eating disorders (ie, anorexia nervosa, bulimia nervosa, and eating disorder otherwise specified) has been questioned. Milos et al (2005) feel these disorders have so much in common they might be viewed as a single entity. These researchers do point out that anorexia nervosa is the most stable of the 3 eating disorder diagnoses.

Frequency

United States

Anorexia nervosa, meeting full Diagnostic and Statistical Manual, Fourth Edition, Text Revision (DSM-IV-TR) criteria, has been found to occur in 1 out of 100-200 females in late adolescence and early adulthood. Individuals who are subthreshold for the disorder are encountered more commonly. Incidence rates have increased in recent years. A familial pattern has been noted.

International

Rates of anorexia nervosa are similar in all developed countries with high economic status. The disorder is far more prevalent in industrialized societies where food is abundant and thinness is a measure of feminine attractiveness.

Mortality/Morbidity

Mortality associated with anorexia nervosa is high; 6-20% of patients eventually succumb to the disorder. Death usually is secondary to starvation or suicide. In addition, death can result from electrolyte issues or infections due to heightened vulnerability.

Race

While frequency of anorexia nervosa is significantly higher in white populations than in nonwhite populations, the coexistent effect of socioeconomic class is difficult to isolate.

Sex

More than 90% of cases occur in females. However, it should be emphasized that males represent approximately 10% of anorexia nervosa cases, a fact that often is overlooked.

Age

Although more commonly the illness begins between early adolescence (13-18 y) and early adulthood, earlier-onset and later-onset are encountered. In some patients with early-onset (ie, age 7-12 y), obsessional behavior and depression are common. In a few cases, exacerbations of anorexia nervosa and symptoms similar to obsessive-compulsive disorder have been associated with pediatric infection-triggered autoimmune neuropsychiatric disorders.

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

History

• Interviews are necessary for establishing the diagnosis. Clinicians should be familiar with the DSM-IV-TR and its criteria for diagnosis (see Pathophysiology). Interview issues to consider include the following:
• • Be aware that illness denial is common. Persons who are anorectic are notoriously unreliable informants.
  • Screening for comorbid psychiatric factors, including substance abuse/dependence, mood disorders, social phobia, obsessive-compulsive disorder, and personality disorders (most commonly cluster C) is necessary.
  • Be aware that eating disorders are more common among competitive athletes. Female athletes are especially at risk in sports such as gymnastics, ballet, figure skating, and distance running. Males in sports such as bodybuilding and wrestling also are at greater risk. Extreme exercise appears to be a risk factor for developing anorexia nervosa, especially when combined with dieting.
  • Treatment ambivalence is common, so acceptance and compassion from the interviewer is important.
  • Data may be gathered from collateral sources.
• Structured interviews may assist in information gathering for assessment purposes. Examples include the following:
• • Clinical Eating Disorder Rating Instrument (CEDRI)
  • Eating Disorder Examination (EDE)
  • Interview for Diagnosis of Eating Disorders (IDED)
  • Structured Interview for Anorexia and Bulimia Nervosa (SIAB)
• Self-report questionnaires provide a method for obtaining more detailed information regarding various dimensions of eating-related symptomatology and more general psychopathology.
• • These serve as screening instruments for the presence/severity of symptomatology.
  • The findings help guide treatment planning by identifying issues that require attention.
  • Responses may reveal other psychiatric symptomatology.
  • They may be repeated, thus helping to assess progress.
• Dimensions for self-report questionnaires and related tools are as follows:
• • Body image disturbance
  • Body dissatisfaction subscale of the Eating Disorder Inventory (EDI)
  • Body Shape Questionnaire
• Maladaptive eating attitudes, behaviors, and cognitions can be elicited using the following:
• • Eating Attitudes Test
  • Eating Disorder Inventory
• General psychopathology can be assessed using the following:
• • Symptom checklist
  • Beck Depression Index
• Self-monitoring may involve recording such things as daily times of consumption, what was consumed, and in what quantities.
• • Patients need to be encouraged to participate in this activity and to record accurately and immediately after eating (ie, an eating diary).
  • Clinicians may develop their own forms or use established forms (eg, IDED).
  • Family members and roommates can check reliability.
  • Two weeks of monitoring often is recommended before beginning psychotherapy. This can be modified, according to the clinician's judgment.
  • Expect some initial resistance.

Physical

Physical Complications of Anorexia Nervosa

• Physical examination
• • Along with the physical complications noted, physical examination of patients with anorexia may reveal a number of important issues.
  • The patient should be weighed. The patient's appearance may be marked by significantly reduced weight, which, in some cases, may be to the point of emaciation.
  • Skin in many patients with anorexia may develop lanugo, characterized by downy soft body hair on the face, volar forearms, and other surfaces of the body. This may be accompanied by a loss of scalp hair. Brittle nails and dry skin may be present with a yellowish discoloration, probably secondary to carotenemia.
  • Bone may be affected with osteoporosis and decreased calcium, decreased phosphorus, and decreased magnesium.
  • Teeth in patients who engage in purging may have decalcification of the lingual, palatal, and posterior occlusal surfaces due to the effects of the acidic gastric contents of vomit. The amalgams, which are resistant to acid, may end up projecting above the surface of the teeth.
  • Cardiovascular
    • Starvation frequently is accompanied by bradycardia and low blood pressure. The bradycardia can be profound at times, despite restricted fluid volume.
    • Conduction abnormalities occasionally are present, possibly resulting from hypokalemia and less frequently resulting from other fluid and electrolyte abnormalities (ie, hypomagnesemia, hypocalcemia, and hypophosphatemia).
    • Cardiomyopathy can result from excessive, aggressive refeeding. The use of ipecac may aid the development of cardiomyopathy.
    • Weight loss also can be associated with the development of mitral valve prolapse.
    • ECG abnormalities may occur, including prolongation of QT interval, which may predispose patients with anorexia to life-threatening arrhythmias, decreased QRS amplitude, nonspecific ST segment changes, and T-wave changes.
  • Pulmonary: Spontaneous pneumothorax and pneumomediastinum have been observed, although the pathophysiology of this is not clear.
  • Fluid and electrolyte abnormalities may include dehydration, rebound peripheral edema, low sodium, low potassium, low chloride, metabolic alkalosis, low magnesium, and low phosphate.
  • Gastrointestinal complications
    • These may include reduced taste, parotid enlargement, esophageal trauma and/or dysfunction, delayed gastric emptying, peptic ulcers, gastric dilatation, superior mesenteric artery syndrome, malabsorption, duodenal dilation, jejunal dilation, damage to the mesenteric plexus due to laxative use, pancreatitis, and liver hepatitis.
    • Metabolic concerns may include impaired glucose tolerance, increased cholesterol levels, beta-hydroxybutyric acid increase, protein deficiency (rare), increased carotene, zinc deficiency (rare), impaired temperature regulation, and sleep deficiencies (less deep sleep, more disrupted sleep).
  • Renal system concerns may include prerenal failure (dehydration), dyscontrol of antidiuretic hormone secretion, hypokalemic nephropathy, and renal stones.
  • Endocrine system concerns may include abnormal hypothalamic-pituitary-gonadal axis, abnormal hypothalamic-pituitary-adrenal axis, abnormal menses, and delayed puberty.
  • Hematological system concerns may include anemia, leukopenia, thrombocytopenia, and abnormal cytokines.
  • Neurological system: Electroencephalogram, CT scan, and MRI generally demonstrate enlarged ventricles and increased ventricle-brain ratios in patients with anorexia when compared to age-matched and sex-matched controls. These abnormalities generally normalize with weight gain.
• Mental status
• • Importantly, note that anorexia nervosa is a multifaceted disorder that requires comprehensive multidimensional assessment. Furthermore, anorexia nervosa is characterized by considerable heterogeneity in symptomatology and comorbid psychopathology (ie, mood disorders, anxiety disorders, personality disorders, and substance abuse disorders). Nevertheless, some general comments may be made about what to observe for when evaluating the mental status of these patients.
  • Orientation: Generally speaking, patients with anorexia typically are well oriented to time, person, and place and usually have reasonably good reality testing.
  • Affect often is depressed.
  • Appearance usually is characterized by being well-groomed and appropriately dressed. Commonly, females wear loose clothing designed to disguise their emaciation, despite the fact that the patient is convinced she is overweight.
  • Hallucinations and formal delusions are not commonly present. However, body image disturbance frequently is present and, in some cases, may border on delusional. Multiple facets of body image disturbance may include body image distortion (ie, weight over estimation), body image dissatisfaction, and body image avoidance. Delusional thinking about appearance may be present when the person has complete conviction about distortions of the reality of her or his actual appearance. Delusional thinking in patients with anorexia usually is confined to situations that draw attention to appearance.
  • Suicide may occur in patients with anorexia. Depression, which is an obvious risk factor, commonly is associated with the disorder. Death may result from increasing malnutrition due to neglect or active suicide. Follow-up studies report that half the mortality observed in this population is the result of suicide.

Causes

The etiology of anorexia nervosa is thought to be a combination of genetic, neuroendocrine, physiological, and psychosociological influences.

• Genetic: Specific genetic factors appear likely to be important in the etiology of anorexia nervosa; however, what this trait may be is unclear.
• • Twin studies have shown the disorder to run in families.
  • Additional abnormalities in 5-hydrocytryptamine (5-HT), noradrenaline, and corticotropic-releasing hormone (CRH) function have been observed in patients who have recovered from anorexia.
• Neuroendocrine: A substantial number of abnormalities of hormone regulation have been described in patients with anorexia nervosa.
• • One hypothesis postulates that hypothalamic abnormalities (eg, neurotransmitter disturbances) are a primary cause of dysfunctional eating and neuroendocrine dysregulation in anorexia. This theory has not been substantiated.
  • The starvation hypothesis postulates that abnormal hormone and neurotransmitter regulation result from reduced caloric intake, suggesting neurotransmitter and neuroendocrine changes in patients with anorexia appear to be an adaptation to a state of starvation.
• Physiological: Some physiological features have been proposed to act to sustain fasting in persons who are anorectic, although these starvation consequences are not viewed to precipitate the disorder. Several hypotheses have been proposed.
• • Gastric emptying is delayed in persons who are anorectic and who are restricting their diet.
  • Levels of cholecystokinin (CCK), a brain-gut peptide with established roles in the modulation of both food intake and gastric emptying, differ in the plasma of patients with eating disorders and in controls.
  • Patients with anorexia rate satiety higher whether gastric emptying is prolonged or not.
  • Implications: Altered gastric emptying sets off a pathophysiologic reaction in patients with anorexia, which helps sustain a psychosocially induced commitment to dieting. Renourishment may be an important first step in treatment.
• Psychological: A variety of psychological, sociological, and family influences have been hypothesized to influence the development of anorexia nervosa.
• • Psychodynamic theories view anorexia as a failure to separate, individuate, and develop autonomy from the primary caregivers. Research on normal female development proposes that the female personality develops through attachment to others. The female confirms her worth through interpersonal relationships. Cultural changes have led women to devalue relationships in favor of autonomy and independence. Steiner-Adair proposes that the incidence of eating disorders has erupted due to an unrealistic emphasis on autonomy in women. The well-rounded mother is associated with mothering and interdependence. Thus, a person with anorexia, by rejecting symbolic parts of her body, is colluding with the current cultural norm.
    • Self-psychology theories: Geist proposed the mother of a child with anorexia allowed identification by the daughter but was unable to express any thoughts or feelings different from her own. Subordinating her self-needs to her mother's needs, the child turns to the father for mirroring and empathy. This bond becomes threatened by sexual maturation, which explains, in part, the onset of symptoms in adolescence.
    • Psychoanalytic theory adheres to the notion that symptoms serve as a defense, which masks an underlying core set of more primitive issues and dynamics. One such central issue is a fear of and resistance to growing up. Beneath this issue, psychoanalytic folklore describes an even more primitive core dynamic known as oral impregnation. In oral impregnation, the female believes if semen is swallowed she will become pregnant. In fact, fear of fatness has been viewed as a rejection of any possible pregnancy. Once the underlying core dynamics are recovered and made conscious (ie, the return of the repressed), the anorexic symptoms reportedly dissipate.
  • Family theories view eating disorders as a method used by the female patient as a cry for help for a conflicted and dysfunctional family. Anorectic families have been described as enmeshed, vacillating between overprotectiveness and abandonment. Minuchin noted that the maintenance of the symptomatic child often defused parental conflicts, and when the symptomatic child matured, the balance of the family became disrupted.
  • Cognitive-behavioral theories: Anorexia nervosa is conceptualized as a learned behavior maintained by positive reinforcement. The individual utilizes excessive dieting to lose weight and, subsequently, is reinforced by peers and society. Being overweight receives negative reinforcement, disapproval, and sometimes ridicule. Reinforcement for weight loss can become so powerful that the individual maintains the anorexic behavior despite threats to health and well-being.
• Media influences: Brumberg (1988) reports that a multitude of social pressures have been promoting dietary restraint, ie, books and magazines touting keys to caloric counting, the fashion industry promoting slimness, the television and film industry's message that thinness is associated with sexual allure and professional success, and the emphasis on physical fitness and athleticism. Anorexia has been, in fact, arguably described as an extension of determined dieting.

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Other Problems to be Considered

Issues other than anorexia nervosa may cause significant weight loss. A physician probably will not observe that the patient has a distorted body image or desire for further weight loss.

Alcohol and Substance Abuse Evaluation
Alcoholic Ketoacidosis
Anxiety Disorders
Bowel Obstruction, Large
Bowel Obstruction, Small
Brain tumors
Gastrointestinal disease
Thyroid storm
Pediatrics, Dehydration
Pediatrics, Diabetic Ketoacidosis
Shock, Hypovolemic
Chronic infections
Malignancies

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Lab Studies

• Some individuals with anorexia nervosa have normal laboratory findings; however, the semistarvation characteristic of the disorder can affect most major organ systems. Induced vomiting and/or abuse of laxatives, diuretics, and enemas also can lead to abnormal laboratory findings.
• • Complete blood count
  • Chem-7 (chlorine, carbon dioxide, potassium, sodium, BUN, creatine, glucose, calcium)
  • Beta human chorionic gonadotropin (bHCG)
  • Consider extended chemistries to include total protein, liver function tests, and creatine kinase (CK)
  • Urinalysis
  • Fecal occult blood
  • Ethanol and dangerous drug screen
  • Serum erythrocyte sedimentation rate (ESR) and thyroid function tests - Unlikely to alter emergency department management but may be sent from that department

Imaging Studies

• Brain imaging - Increase in ventricular-brain ratio secondary to starvation often observed
• Chest and abdominal x-rays - May be indicated
• Electrocardiogram

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Medical Care

Treatment of anorexia nervosa is challenging and complicated. Frequently, the disorder has been present for some time prior to presentation for treatment. Denial of the seriousness of the illness is common in patients. Patients' family members often prefer physiological over psychological explanations for the disorder. Family communication patterns frequently are dysfunctional.

• Anorexia nervosa still is not fully understood but appears to be multidetermined. Consequently, treatment should be multimodal and include a combination of approaches. Flexibility and realistic goals are essential. Long-term follow-up may be necessary.
• Inpatient hospitalization may be necessary for the following:
  • To achieve weight restoration or interrupt steady weight loss in patients who are in medical danger
  • To interrupt medical risks or complications that binging, vomiting, and/or laxative use may create
  • To evaluate and treat other potential serious physical complications
  • To manage associated conditions (eg, severe depression, suicide risk, substance use disorders)
  • Observational data suggest that when hospitalization is used, patients with eating disorders respond better in units that specialize in eating disorders compared with general medical units, perhaps because nutritional rehabilitation and specialization in mental health treatment are more likely to be provided (Wolfe, 2003).
• Day treatment/partial hospitalization
  • Provides structure around mealtimes
  • Offers intensive therapy without breaking off outside supports and challenges
  • More economical than full hospitalization
  • Provides a useful bridge between inpatient and outpatient care
• Outpatient medical management for patients with chronic conditions
  • May be appropriate when, after careful evaluation, the patient is unresponsive to further psychological treatment
  • Aim is to maintain medical and psychological stability, accomplished by regular meetings in which body weight, electrolytes, and vital signs are checked, and medical referral to specialists is available as needed
• Education-based interventions
  • Diet, meal planning
  • Nutritional management
  • Self-help interventions
• Psychotherapy: In the overall treatment of anorexia nervosa, a strong therapeutic relationship, based on trust and understanding, and conducted over an extended time frame, typically is a crucial element of any treatment approach. Additionally, psychotherapy is essential for effective utilization of other treatment modalities. The following are types of psychotherapy that clinicians have found useful:
• • Individual: Clinical consensus suggests that psychotherapy alone generally is not sufficient to treat severely malnourished patients with anorexia nervosa. However, once malnutrition is corrected and weight gain has started, considerable agreement exists that psychotherapy can be very helpful.
  • Psychodynamic
  • Self
  • Interpersonal
  • Cognitive-behavioral
  • Group: Some practitioners have used various modalities of group psychotherapy programs adjunctively in the treatment of anorexia nervosa, such as psychodynamically oriented group psychotherapy to address underlying personality disorders. However, practitioners also have found that group psychotherapy programs conducted during the acute phase among malnourished patients with anorexia nervosa may be ineffective and sometimes can have negative therapeutic effects (eg, patients may compete for who can be the thinnest).
  • Family therapy and couples therapy: These frequently are useful for both symptom reduction and dealing with family relational problems that may contribute to maintaining the disorder. Particular help should be offered to patients with eating disorders who are themselves mothers, ie, to minimize the risk of transmission of eating disorders.
• Managing medical complications: Many patients with anorexia require ongoing physician monitoring during treatment, depending on their underlying conditions. Common conditions that require repeated monitoring include the following:
  • Electrolyte status and dehydration (eg, potassium, calcium, magnesium, phosphate levels)
  • Hypoestrogenemia, amenorrhea, and osteoporosis
  • Frequent dental evaluations
  • Input into nutritional support
  • Medical emergencies (eg, cardiac arrhythmias, symptomatic electrolyte disturbances, significant GI bleeding)
  • Infertility
  • Pregnancy
• Treatment of patients with personality disorders:
  • Research literature suggests a significant number of patients with eating disorders also have personality disorders.
  • When personality pathology is present in individuals with the binge-eating/purging type of anorexia nervosa, they are most likely to exhibit cluster B personality pathology (particularly borderline or histrionic personality features).
  • Borderline personality is the predominant axis II pathology associated with the binge-eating/purging type of anorexia nervosa.
  • Cluster C has been associated with anorexia nervosa (specifically avoidant, obsessive-compulsive, or dependent personality disorders).
  • Effective treatment must recognize and attend to the personality disorder issues.
  • Treatment of these individuals is difficult, takes longer than with individuals who do not have personality disorders, and typically requires considerable expertise at the individual psychotherapy level.
  • Some patients show good outcomes, while others do not.
  • An important prognostic indicator is an individual's ability to develop a constructive attachment to the therapist.
• Addressing treatment refusal issues
  • Seek to engage in a strong voluntary therapeutic alliance.
  • Reasons for treatment refusal should be identified.
  • Make sure the patient understands treatment recommendations.
  • Expect the patient to want to negotiate aspects of the treatment plan.
  • Promote autonomy to the greatest extent possible.
  • Realistically assess the risks and benefits of imposed treatment.
  • Avoid power struggles.
  • Allow patients as much control as possible without endangering the recovery process.
  • Assure treatment interventions are not punitive.
  • The family should be involved in the treatment.
  • Obtain ethical and legal clarification and support when considering imposed treatment.
  • Only consider legal means of imposing treatment when refusal is judged to have serious risk.
  • Consider alternative approaches when treating chronic cases.
  • Treatment refused at one point may evolve into a welcomed option at a later point.

Consultations

An important prognostic indicator is an individual's ability to develop a constructive attachment to the therapist.

MEDICATION

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

At this point in time, numerous sources suggest pharmacotherapy has limited value in treating patients with anorexia and should not be the sole treatment modality.

Antidepressant medications may be considered after weight gain, when the psychological effects of malnutrition are resolving, because these medications have been shown to be helpful with weight maintenance. In one controlled trial, patients with anorexia nervosa who restored their normal weight took fluoxetine (average 40 mg/d) after hospital discharge had less weight loss, depression, and fewer rehospitalizations for anorexia nervosa during the subsequent year than those who received placebo. Selective serotonin reuptake inhibitors (SSRIs) are commonly considered for patients with anorexia nervosa whose depressive, obsessive, or compulsive symptoms persist in spite of or in the absence of weight gain. Additionally, SSRI antidepressant medications may be beneficial in dampening compulsivity in patients with the restricting type and impulsivity in patients with the binge-eating/purging type.

Other psychotropic medications most often are used to treat psychiatric symptoms that may be associated with anorexia nervosa. Examples include low doses of neuroleptics for marked obsessionality, anxiety, and psychoticlike thinking (eg, olanzapine at a dose of 2.5-10 mg/d) and antianxiety agents used selectively before meals to reduce anticipatory anxiety concerning eating. Although estrogen replacement sometimes is used to reduce calcium loss (thereby reducing risks of osteoporosis) in patients with anorexia who have chronic amenorrhea, existing evidence in support of hormone replacement therapy in these cases is marginal at best. Promotility agents such as metoclopramide are commonly offered for the bloating and abdominal pains due to gastroparesis and premature satiety observed in some patients.

For the subgroup of patients with binge-eating disorder, a study (Shapiro, 2000) found topiramate may have a favorable effect. Topiramate is usually started at 25 mg at night and increased by 25-50 mg/wk according to the patient's response and side effect profile, to a maximum dose of 1400 mg/d; it is typically given bid or qhs as tolerated. Study results found 9 of 13 patients with binge-eating disorder responded favorably.

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Further Outpatient Care

• See Medical Care.

Deterrence/Prevention

• Primary prevention targets the following:
• • Societal concerns with thinness
  • Providing knowledge to the general public about the dangers of dieting and anorexia nervosa
  • Emotional problems of female adolescents and young adults (because they are the high-risk group)
• Secondary prevention objectives are the following
• • Successful early recognition
  • Effective early intervention
• In patients 18 or younger, family therapy may be more effective in preventing relapse than individual supportive therapy (Yager 2005, Dare 2001).

Patient Education

• Providing knowledge to the public about the dangers of dieting and anorexia nervosa may help in prevention.
• Eating disorders are multifaceted behavior problems that require a multidimensional approach. Assessment of the family is important whenever possible to include education about the disorder. Interviews, self-report questionnaires, and self-monitoring may prove useful for providing an organizational framework to guide the assessment process.
• For excellent patient education resources, visit eMedicine's Eating Disorders Center and Women's Health Center. Also, see eMedicine's patient education articles Anorexia Nervosa and Amenorrhea.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Medical/Legal Pitfalls

• Patients who have been sexually abused or who have otherwise been the victims of boundary violations are prone to stir a profound need to rescue the patient, which can occasionally result in a loosening of the therapeutic structure, loss of therapeutic boundary-keeping, and a sexualized countertransference reaction. In some cases, these countertransference responses have led to overt sexual acting out and unethical treatment on the part of the therapist, which may compromise treatment and also severely harm the patient. Clear boundaries are critical in the treatment of all patients with eating disorders, not only those who have been sexually abused, but also those who may have experienced other types of boundary intrusions regarding their bodies, eating behaviors, and other aspects of the self by family members and others.

ACKNOWLEDGMENTS

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Brenda Williams-Wilson, MD to the development and writing of this article.

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

• American Psychiatric Association. In: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association Press;2000.
• American Psychiatric Association. Practice Guidelines for Eating Disorders. Washington, DC: American Psychiatric Press; 2001.
• Beck AT. Depression: Causes and Treatment. Philadelphia, Pa: University of Pennsylvania Press; 1972.
• Berkman JM. Anorexia nervosa: anorexia, inanition and low basal metabolic rate. Am J Med Sci. 1930;180:411-424.
• Bliss EL, Branch CH. Anorexia Nervosa: Its History, Psychology, and Biology. New York, NY:. Hoeber;1960.
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Article Last Updated: Apr 17, 2006