Anorexia nervosa is a complex psychological disorder typically affecting young people between the ages 15 and 18. It has been shown to be inherited from parents in about 70% cases. Personality traits, such as perfectionism, body dissatisfaction, and obsessive thoughts may predispose patients to it. Other predisposing factors are also implicated, such as having a history of anxiety, depression, or substance abuse, or physical or sexual abuse.
Environmental factors such as media influences and peer pressure may lead a susceptible individual to lose excessive weight escalating to an obsessive state with restrictive eating and body size.
There are two subtypes: restricting subtype, in which patients drastically reduce food consumption; and the binge-eating/purging subtype, in which patients lose weight by purging methods such as forced vomiting and abusing laxatives. They may also exercise excessively in an effort to lose weight. They may develop odd dietary rituals, such as cutting food into tiny pieces, eating only at certain times, and weighing food.
The following need to be present in order to diagnose anorexia nervosa:
- Body weight less than 85% of normal
- Significant fear of gaining weight or growing fat,
- Misperception of own weight or body shape
- Absence of at least three consecutive periods in females who previously menstruated
The treatment includes
- nutritional support,
- psychological counseling, and
- behavioral modification.
Treatment may be on an outpatient basis, in a residential or partial hospitalization unit, or on an intensive inpatient basis. The aggressiveness of the treatment is based on the patient’s weight:
- >15% loss body weight will require inpatient treatment or a highly structured outpatient program.
- <15% weight-loss threshold can be treated less aggressively on an outpatient basis.
It is also advised to consider include how quickly a patient has lost weight and whether a serious medical complication is present. If the patient is young and has had anorexia nervosa for less than three years, a three-phase treatment called the Maudsley method is employed:
- Phase 1 – encourage patients to eat more, using family for support..
- Phase 2 – as eating becomes more normal and weight improves, try to identify and change family dynamics that may impede recovery.
- Phase 3 – once a healthy weight is attained, work with patients and families to improve relationships and to help the child become more independent.
Severely affected patients are effectively starving, which affects their thinking, – they’re typically negative, obsessive, and manipulative. At this stage, psychotherapy is generally ineffective. But once the patient is stable, psychotherapy should be done to provide support and encourage her to gain weight. Positive reinforcement and close monitoring are a good combination. When setting goals, it’s reasonable to aim for a gain of 2 to 3 pounds per week (or up to1.5 pounds in an outpatient setting.
Medication options, which should be avoided if possible,
include antidepressants (selective serotonin reuptake inhibitors (SSRIs)) or antipsychotics with psychotherapy.
The evidence is strongest for using psychotherapy to improve the chances of recovery in adults. Cognitive behavioral therapy helps patients to recognize and change distorted or maladaptive thinking about food, while interpersonal or psychodynamic therapy helps them to improve relationships with other people.
The main challenge is to prevent relapse because half of patients who successfully gain weight relapse within one year of being discharged. Patients’ attitudes towards food and weight may never return to normal.
