Approach Considerations
Anorexia nervosa is difficult to treat because of the shame, denial, and lack of insight concomitant with the disorder. [104] Medical management is directed toward correcting and preventing the disease’s complications. Reestablishing normal eating patterns is crucial to restoring the patient’s health. [105]
Hospital admission may be indicated for patients who are extremely ill, have cardiac dysrhythmias, or have severe metabolic abnormalities. Most patients will be admitted to medical facilities for refeeding, referred to psychiatric facilities and counseling if medically stable, or be managed on an outpatient basis. [106, 107]
Outpatient treatment should be undertaken only with very close monitoring, such as weekly weight measurement with the patient wearing only a gown.
As with all psychiatric and behavioral emergencies, care must be taken to prove and document competency upon discharge. Many patients with anorexia nervosa may have additional psychopathology, which may leave them incapacitated during an anorexic crisis. If doubt remains, the patient must be admitted for more thorough psychiatric and physiologic monitoring or be discharged in the care of a competent caretaker. [103]
Transfer to an inpatient psychiatric facility may be the disposition for patients who are medically safe for discharge but who require aggressive inpatient psychiatric treatment of their disorder.
Research has found a correlation between low BMI in anorexia nervosa and altered physical activity patterns providing an implication that restriction on physical activity might help restore a healthy BMI. [108]
Pharmacologic Therapy
Acute pharmacologic treatment of anorexia nervosa is rarely required. However, vitamin supplementation with calcium should be started in patients, and although estrogen has no established effect on bone density in patients with anorexia nervosa, estrogen replacement (ie, oral contraceptives) has been recommended for the treatment of osteopenia; the benefits and minimal effective dose of the hormone are being explored. [109]
Types of Psychological Therapy
Various psychological therapies have proven helpful in treating patients with anorexia nervosa, including the following [5, 6] :
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Individual therapy (insight-oriented)
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Cognitive analytic therapy
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Enhanced cognitive-behavioral therapy (CBT-E)
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Cognitive remediation therapy (CRT)
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Interpersonal therapy (IPT)
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Motivational enhancement therapy
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Dynamically informed therapies
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Group therapy
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Family-based therapy (FBT)
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Specialist supportive clinical management (SSCM)
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Conjoint family therapy
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Separated family therapy
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Multifamily groups
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Relatives and caregiver support groups
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Attention bias modification training
Younger individuals with anorexia nervosa, especially adolescents, may respond best to family-based treatment (FBT), which appeared superior to individual therapy. [7] The recovery rate for adults appeared higher with CBT, however other treatments such as SSCM and the Maudsley method (MANTRA) showed an outpatient recovery rate of 15% in maintaining remission from anorexia nervosa. FBT also appeared superior to CBT although the rate of recovery from CBT-E was slightly improved over CBT. [110, 7, 111]
A modification of CBT called CRT (cognitive remediation therapy) may be more effective in helping the patient to gain better cognitive flexibility, and is a manual-based program especially effective for motivated persons. [111]
Caregivers' interactions are most helpful when stigma is lessened and collusion, avoidance, accommodation to the illness, and negative expressed emotion such as overprotection and hostility were avoided. [74]
A review by Mercado et al. found that Attention Bias Modification Training (ABMT) has the potential to modify maladaptive eating behaviors related to anxiety around food and eating and propose two mechanistic models: (1) ABMT increases general attentional control (which will improve control over disorder-relevant thoughts) or (2) ABMT promotes stimulus re-evaluation possibly via changes in the subjective value of food stimuli (i.e., reward processing) or via habituation, with both resulting in a reduced threat response. [112]
Refeeding Strategies
Nutrition is an important part of the treatment for the individual with anorexia nervosa. A nutritionist or dietitian should be an integral part of the treatment plan, because the well-recognized refeeding syndrome can occur during the early stages of refeeding the patient with anorexia. This syndrome encompasses cardiovascular collapse, starvation-induced hypophosphatemia, and dangerous fluctuations in potassium, sodium, and magnesium levels.
The process of refeeding must therefore be undertaken slowly, with modest increases in metabolic demands. Assessment of vitamin D and calcium intake is helpful in the design of a successful refeeding plan. [24]
Assessment of linolenic acid, retinol, vitamin A, vitamin D, and pantothenic acid levels can also be helpful, because early in anorexia, levels of vitamin A can be elevated, causing symptoms such as dizziness, cerebral edema, and nausea, as well as bone mineral loss. This tends to exacerbate worsening of the anorexia, thereby worsening the patient’s nutritional and general medical status. [113]
Tube feeding must often be initiated on an inpatient basis when the patient's weight is less than or at 85% of expected weight and/or less than the third percentile for BMI, [114] as outpatient refeeding can be too uncomfortable, and the weight gain can be too rapid for the patient to tolerate, resulting in the patient sabotaging treatment. Tube refeeding does not impair efficacy of any psychological therapies. [115]
Rio et al (2013) and Mehler et al (2010) have proposed the following strategies to avoid the refeeding syndrome: [116, 114]
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Identify patients at risk.
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Measure serum electrolyte levels and correct abnormalities before refeeding, as low levels of potassium, magnesium, and phosphate may be a risk factor for refeeding syndrome
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Obtain serum chemistry values every 3 days for the first 7 days and then weekly during the rest of the refeeding period
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Attempt to increase daily caloric intake slowly from 1000 to 1900 kcal/day by 200-300 kcal every 3-5 days until a sustained weight gain of 1-2 pounds (0.45-0.9 kg) per week is achieved (rapid refeeding can lead to excessive bloating, edema, and, rarely, congestive heart failure)
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Monitor the patient carefully for development of tachycardia [117] or edema
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Monitor for pellagra and administer niacin supplementation if needed [118]
A small, but well-done, study by Garber et al of 35 hospitalized patients with anorexia nervosa found that increased fluid output and less-dilute specific gravity at the start of refeeding may be causally related to the common finding that initial weight loss occurs at the start of treatment and continues until day 8. Thus, it may be better to refeed anorexic patients with a higher caloric intake (average, 1966 kcal) than has been recommended by the American Psychiatric Association and the American Dietetic Association, which generally results in a low weight gain (1 kg/wk maximum on an initial 1200-kcal/day diet) following initial weight loss. [119]
In the Garber study, refeeding more aggressively did not result in refeeding syndrome, as phosphorus levels did not decrease to an unacceptable level. The result was a reduction in the duration of hospital stay by almost 1 day, without increased risk of medical complications. [119]
Family-Based Therapy
Psychological issues encompass the coping strategies engendered by eating disorders. According to Kreipe and Birndorf, the treating clinician may threaten the homeostatic balance that has been achieved within the family system secondary to dealing with the patient with anorexia; negative emotions, such as anger and denial, may be directed at the clinician. [92]
Individuals with anorexia nervosa may respond best to family-based treatment, also known as the Maudsley method, an established therapeutic modality for achieving and maintaining remission from anorexia nervosa. [110, 26]
This treatment modality should take into account the level of negative expressed emotion in the patient’s family and be performed conjointly only if that level is not excessive. [48, 5, 120] Simultaneous sessions can be more productive because, if patients feel intense negative emotions from their families, they are more likely to be noncompliant with treatment.
A large, randomized, controlled study of 121 adolescents and young adult subjects found that although family-based therapy was equally as effective as adolescent-focused therapy, [121] family-based therapy resulted in more successful maintenance of improvement after 12 months, as measured by superior outcomes at 6 months and 12 months posttreatment.
For some adolescents with more severe anorexia nervosa, extending family-based treatment beyond 20 weeks' duration may be needed. One study of 69 medically unstable adolescents found that continuing family-based treatment beyond 20 weeks' duration improved outcomes. [122]
Although an earlier meta-analysis/review did not find a difference in outcome between family-based therapy and educational interventions, that review incorrectly grouped several studies together that were different in approach. [123] Specifically, some of those studies did not have a standardized approach and had an insufficient number of subjects.
Behavioral Therapy/Psychotherapy
Psychodynamic psychotherapy in combination with behavioral strategies is indispensable in patients with anorexia nervosa. Randomized, controlled trials show that CBT is very effective, especially in the setting of tube feeding. [124]
A flexible approach to the use of CBT or IPT is important and should be tailored to the individual, whenever possible, especially taking into account expressed emotion. [125] Successful CBT can yield better results than community-based treatment, especially in the presence of specific issues (eg, sexual abuse, traumatic events) more likely to respond to specific subtypes of CBT, such as trauma-focused CBT or exposure therapy with response prevention. [47, 126, 127, 128]
Comparisons of Psychotherapies
IPT and CBT versus nonspecific therapy
In a study by McIntosh et al, some patients with anorexia nervosa who received nonspecific management (in which clinical management was combined with supportive psychotherapy) appeared to have outcomes as good as or better than those of patients who received IPT or CBT. [129] The reason for this may be that in the nonspecific approach, the therapy was provided by experienced clinicians, was practiced according to a detailed treatment manual, and instituted psychoeducation with a strong focus on normalizing eating (with approaches such as smart food selection and quantities needed to gain weight). [129]
Family group psychoeducation versus family therapy
A study by Geist et al of 25 adolescent females with anorexia nervosa suggested that family group psychoeducation is as useful as family therapy (as measured by weight gain in patients) in newly diagnosed, medically compromised patients, while being more cost-effective. [130]
Psychopharmacologic Therapy
Psychopharmacologic treatment in anorexia nervosa is generally unhelpful, although fluoxetine (Prozac), a selective serotonin reuptake inhibitor (SSRI), may stabilize recovery in patients who have already attained 85% of their weight. If SSRIs are used, however, patients should be carefully monitored for hypomanic or manic adverse effects.
Evidence-based studies show that pharmacotherapy is more effective when combined with CBT and should not be used alone.
Psychotherapy with adjunctive low-dose olanzapine may be useful for anorexia nervosa during inpatient treatment, especially in the context of anxiety, obsessive eating-related ruminations, and treatment resistance due to failure to engage. [10]
Inpatient Care
Individuals with anorexia nervosa who are at risk medically or psychiatrically require inpatient treatment. Indications for hospital admission include the following:
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Low weight (85% or less of expected weight and/or less than the third percentile for BMI) [114]
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Lack of any weight gain
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Significant edema
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Physiologic decompensation including, but not limited to, the following: (1) severe electrolyte imbalance (life-threatening risks created by sodium and potassium derangements), (2) cardiac disturbances or other acute medical disorders, (3) altered mental status or other signs of severe malnutrition, and (4) orthostatic differential greater than 30/min
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Temperature less than 36°C
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Pulse below 45 beats per minute
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Psychosis or a high risk of suicide
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Symptoms refractory to outpatient treatment
In order to preserve his or her self-esteem and to prevent suicidality and feelings of hopelessness, inpatient management should be approached in such a way as not to seem like punishment to the patient. The goals of inpatient therapy should be fully discussed with the family and the patient, including elements such as developing a healthy meal plan, addressing underlying conflicts (such as low self-esteem) and planning new coping strategies, and enhancing communication skills.
It is essential to monitor the patient's weight, vital signs, and serum electrolyte levels. Although weight gain is a primary goal of treatment, the weight gain should not be excessive, because rapid refeeding can lead to refeeding syndrome: excessive bloating, edema, and, rarely, congestive heart failure (CHF). Leptin and cortisol levels may be helpful in predicting the time to weight recovery. [131]
Activity
Limited physical activity (eg, sports, exercise classes) is recommended. By limiting activity, energy expenditure is limited, thus assuring a balanced weight. Moreover, without structure, patients may exercise in potentially harmful ways and at very high intensities. Limitation of activity may also motivate the patient to maintain healthy eating habits in order to ensure a rapid return to favorite activities. Note that the disadvantage of curtailing activity is the removal of the patient's coping mechanism to deal with stress.
Anorexia nervosa is based on caloric restriction and increased caloric expenditure that leads to excess exercise to control weight. Previous studies have described the use of exercise programs for hospitalized inpatients in which exercise was exchanged for weight gain and compliance. However, no guidelines were set forth in terms of type, intensity, and duration of exercise.
Thien et al looked at a standard program designed for outpatient use, graduated in type of exercise, duration, and level of activity, and demonstrated that both the exercise and the control groups in the study achieved increases in BMI and body fat percentage. However, quality of life was increased in the exercise group, whereas the control group showed a decrease in all aspects of quality-of-life measures, although the difference was not statistically significant. [132]
Consultations
The approach to the treatment of individuals with anorexia nervosa is multidisciplinary. Consultations with specialists in adolescent medicine, nutrition, psychiatry or behavioral-developmental pediatrics, and psychology may be required.
Most cases of anorexia nervosa encountered in the emergency department (ED) will be appropriate for outpatient management if close, planned follow-up is arranged prior to discharge. Consultation with the pediatrician or primary care physician is necessary to arrange follow-up. Urgency of follow-up depends on the patient's condition and how soon the laboratory study results will need to be reevaluated.
Psychiatric consultation in the ED should be considered for patients expressing suicidality, psychosis, or severely disordered thinking. Outpatient psychiatric follow-up is necessary and may be arranged either from the ED or by the primary care provider.
Monitoring
For patients with the mild stage of anorexia nervosa, reevaluate in 1-2 months to check that the weight is not decreasing, that health is maintained, and that the patient has not developed bad eating habits. Surveillance is required to ensure that the patient has not progressed to the moderate stage.
Complications of weight-control habits include the inability to break the cycle of disordered eating as an outpatient and the inability to initiate effective outpatient psychotherapy. [92]
