Nutritional rehabilitation and behavior changes can often correct the medical complications of emaciation and purging. Lost bone density is seldom restored, but nutritional rehabilitation can prevent further bone loss.13 Women who remain amenorrheic for several years after weight restoration tend to be more psychologically disturbed than those who resume menses rapidly.14
Cognitive-behavioral therapy
Other authors have discussed CBT for anorexia nervosa.3,15 In general, the key tasks—operationalizing beliefs, evaluating autonomic thoughts, testing prospective hypotheses, and examining underlying assumptions—are accomplished by assessing anorexia’s distorted cognitions. No satisfactory controlled studies have examined any other type of individual psychotherapy for treating anorexia nervosa.
Alliance building. Patients with anorexia find it difficult to participate in therapeutic relationships. They are terrified of gaining weight and readily drop out of treatment. To build a therapeutic alliance:
- begin by helping the patient develop a history of her significant life events
- proceed slowly, praising her for every small attempt at changing her behavior
- set realistic therapy goals, considering her degree of resistance.
Monitoring. Behavior therapy consists primarily of positive reinforcements for weight gain. For this, we weigh outpatients weekly and inpatients daily. Outpatients are taught to keep diaries of daily food intake, stressful events, and emotional responses to them. The therapist begins each session by examining the patient’s diary with her and discussing how life events affect her eating behavior.
Cognitive restructuring helps patients identify their disturbed cognitions and challenge core beliefs about self-image. In this process, they become aware of their negative thoughts and develop arguments and evidence to support and refute the thoughts’ validity. They then form a reasoned conclusion based on the evidence.
Even if patients do not accept this logical conclusion, we encourage them to behave as if they believe it to be true. By doing this repeatedly, they eventually obtain some symptom relief.
Response-prevention techniques can help stop binging and purging. For example, we may require inpatients to sit together for 1 hour after eating. Because most patients will not vomit in front of each other, they learn how to resist vomiting and eventually experience reduced anxiety without vomiting after a meal.
Problem solving helps patients to reason through difficult food-related or interpersonal situations. The patient states the problem, then generates as many solutions as possible with the therapist’s assistance. She chooses one solution and puts it into effect, usually for 1 week. She then discusses the results with her therapist and decides whether to try another solution.
Family therapy. A family analysis—including a brief psychiatric history and evaluation of interactions—is recommended for all patients who live at home. This analysis can help you decide what type of family therapy or counseling to recommend.
Some families respond well with the parents and patient together in therapy sessions, whereas others are more comfortable with separate counseling. In a recent controlled study, anorectic patients younger than age 18 did equally well whether they were counseled with the family or separately.16
Brief therapy sessions are sometimes the most effective method to address family issues. When this is not possible, you and the patient can discuss family relationships in individual therapy.
Medications
Many medications have been used to treat anorexia nervosa, though few randomized, placebo-controlled studies exist. Because evidence does not support using psychotropics as monotherapy for anorexia nervosa, medication is considered adjunctive to CBT.
Chlorpromazine can help the hospitalized, severely ill patient who is overwhelmed with uncontrollable behavioral rituals and thoughts of losing weight. This antipsychotic helps reduce anorectic preoccupations and anxiety and helps make patients more amenable to therapy.
Start chlorpromazine at 10 mg tid and increase gradually until the patient can eat without extreme anxiety. Usual maximum dosage is 50 mg tid. Monitor blood pressure, tardive dyskinesia, and decreased white blood cell count.
Olanzapine may help induce weight gain and reduce anxiety in anorectic patients.17 Controlled and open-label studies are under way.
We start olanzapine at 2.5 mg/d and increase gradually to 10 or 15 mg/d. At this dosage, patients’ anxiety about eating is usually substantially reduced. Sedation is the most common side effect.
Anorexia patients often refuse to take olanzapine for fear of weight gain. If a patient’s emaciation is life-threatening, we may seek court permission to medicate her involuntarily. We reassure her that we will discontinue olanzapine when she reaches her target weight.
Serotonin in anorexia. Central serotonin pathways modulate feeding behavior. Serotonin antagonists—such as cyproheptadine—increase food intake and weight gain, whereas serotonin agonists—such as selective serotonin reuptake inhibitors (SSRIs)—decrease food intake.
Serotonin pathways also may modulate obsessive-compulsive and impulsive behaviors. Both serotonin agonists and antagonists can be useful adjuncts in treating anorexia nervosa.