Anorexia Nervosa

Treatment Options

The treatment setting for individuals with Anorexia Nervosa vary widely, from the hospital setting, residential centers, partial or day programs, and outpatient therapy. Regardless of the setting, psychoeducation is a critical part of the recovery process. Like its assessment, the treatment for Anorexia Nervosa ideally should be provided by a multidisciplinary team, each with training and experience working with this particular illness. At the bare minimum, this treatment team should consist of both a medical and mental health professional. It ideally should also include specialists in nutrition and psychopharmacology. Psychotherapy services can be administered by a licensed clinical psychologist, clinical social worker, marriage and family therapist, or psychiatric nurse. The team may also include a psychiatrist whose role is either to manage psychotropic medication or provide therapy. A dietician should be included to assess nutritional needs, create an appropriate dietary plan, and to assist in implementation of the plan. Experiential therapies such as art and yoga therapists are increasingly being incorporated in treatment teams.

If an individual is in a severely compromised medical state, hospitalization and/or intensive inpatient residential treatment may be most appropriate with the immediate priorities being restoration of some body weight, management of associated medical symptoms and risks, and reduction of high risk behaviors (such as laxative abuse, purging, etc.). Restoration of weight may be accomplished via intravenous nutrition as the medically compromised individual with Anorexia Nervosa may continue to refuse to eat. In a hospital and/or residential treatment facility, the individual can receive close 24 hour supervision and minimize the risk of “reefeeding syndrome,” a potentially lethal side effect of reinstitution of nutrition in individuals who are in a malnourished state. Guidelines for when hospitalization is deemed necessary vary considerably. Psychological factors that maintain the disease state must then be addressed such as anxiety, depression, distorted body image, increased importance on shape and weight, and family dysfunction. For the majority of individuals with Anorexia Nervosa, outpatient treatments with psychological intervention as the key element are appropriate. Close medical supervision and monitoring is always recommended.

There are numerous treatment modalities that are utilized in Anorexia Nervosa. Therapeutic modality often varies by the training and therapeutic orientation of the clinician. It is recommended that when seeking treatment that consumers investigate the therapeutic background of the clinician and educate themselves about the given probability of effectiveness for that particular therapeutic approach.

Family-Based Therapy (FBT), also known as the Maudsley method, is a manualised form of psychotherapy that has been empirically validated as an effective treatment with good recovery rates for adolescents for Anorexia Nervosa. Rather than viewing the family as dysfunctional unit that contributes to the disease process, FBT involves looking at the family as the major resource in the individuals chance for recovery. The primary goals of FBT is to empower caregivers to take control of refeeding their child until weight is restored and the child is deemed capable of feeding herself again adequately. The therapy involves separating the illness from the patient by emphasizing that the eating disorder is robbing the individual of their personality and they are incapable of thinking clearly until they are nutritionally restored. A cornerstone of this approach is the family meal, held during the therapeutic session in which the clinician observes family dynamics around food and mealtimes and uses the experience to empower caregivers to encourage their child to take one more bite of food than they had initially planned on taking.

Other forms of family therapy may be utilized in the treatment of Anorexia Nervosa that are not based on the Maudsley method and have been less rigorously investigated in treatment studies. These treatments include the family but are typically based more on a family-systems approach which looks at the dynamics within the family that may contribute the onset or maintenance of the eating disorder and work towards resolving these issues and conflicts within the family. All forms of family therapy involve using the family members as supports in the therapeutic process and educating family members about the illness.

Cognitive-Behavioral Therapy (CBT) is a common and widely used form of psychotherapy that involves helping the patient to both change maladaptive ways of thinking (cognitions) and behaving that reinforce and maintain the eating disorder. CBT has been found to be effecting in both adolescents and adults with Anorexia Nervosa. The cornerstone of this treatment is keeping a daily food journal that is reviewed in depth in every session with therapist and patient. The initial goal of treatment is to normalize eating by structuring three meals and two snacks each day. Dieting and the overvaluation of shape and weight are two of the other major targets of therapeutic change.

Interpersonal Psychotherapy (IPT) is based on the theory that all symptoms, regardless of etiology, are effected by interpersonal relationships and that by improving the quality of these relationships, symptom reduction can occur.

Supportive Psychotherapy is a less directive form of therapy that involves principles such as unconditional positive regard, reassurance, and increasing self esteem.

Psychoanalytic Therapy is typically much longer than CBT or FBT and has not been extensively studied in research for the treatment of Anorexia Nervosa. Psychoanalytic therapy is often focused on resolving childhood conflicts that are thought to have played a significant role in current symptoms. The goal is to help the individual to gain insight into the origins and purpose of their symptoms.

Experiential Therapies: When verbal expression is restricted or limited it can be particularly helpful to incorporate alternative modalities of therapy that allow for other forms of emotional expression rather than talk therapy alone. The term “experiential” has been used to describe a variety of therapeutic techniques. Experiential therapies usually refer to expressive forms of therapy that involve action, rather than just a verbal basis of communication. Art, music, dance and movement (such as NIA and yoga), equine (horses), writing and narrative, play, vocational therapies, adventure and hiking therapies are all considered experiential forms of therapy and are becoming increasingly common as adjunctive treatment approaches with Anorexia Nervosa. Gestalt and Rogerian orientations to therapy have also been considered to be “experiential” forms of therapy.

Nutritional Therapies are often utilized as part of a multidisciplinary team. The goals of nutritional therapy are to encourage the patient to eat a more balanced diet and to gradually incorporate more foods into their diet. Dieticians are typically responsible for designating caloric goals, meal planning, creating exchange systems, helping the client with their food journal.

Self-help in the form of books or support groups is not recommended in the treatment of Anorexia Nervosa as the sole treatment modality. Such options are best when incorporated into other forms of treatment as adjunctive.

Psychotropic medication has also been used in the treatment of Anorexia Nervosa. Research generally suggests that no medication alone has been found to be effective in causing recovery in Anorexia Nervosa. When medication is used, it is usually used as an adjunctive form of therapy in addition to other forms of therapy. Selective Seroton Reuptake Inhibitors (SSRI’s) such as fluoxetine may help to manage some of the related depressive and anxious symptoms in Anorexia Nervosa. They also may be effective in helping to maintain therapeutic gains and prevent relapse in combination with other therapies. There is some promising research to suggest that olanzapine, an atypical antipsychotic commonly prescribed in schizophrenia, may help to decrease the delusional-type thinking associated with Anorexia Nervosa and possibly reduce some of the associated anxiety, making other forms of treatment potentially more effective. The tricyclic antidepressants amitriptyline has been investigated as a potential treatment in Anorexia Nervosa due to its potential to cause weight gain, however, the response has been limited with significant undesirable side effects.

Article by Lindsey Ricciardi, Ph.D
Licensed Clinical Psychologist &
Eating Disorders & Obesity Specialist

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