Treatment
Treatment approach to anorexia nervosa is summarized in

Table 26-2.

The initial goal of treatment is to counteract the effects of starvation by promoting weight gain and restoring normal nutritional balance. In mild cases, this may be accomplished on an outpatient basis; in moderate to severe cases, an initial period of hospitalization is usually required.

Weight gain may be accomplished by hyperalimentation or total parenteral nutrition. However, because of the risks of intravenous feedings, most programs utilize behavior modification protocols based on the principles of operant conditioning. Although behavior modification may be effective in promoting initial weight gain, most outcome studies have concluded that behavior modification alone is not sufficient treatment. Lasting recovery occurs only when such methods are used in conjunction with psychotherapy, which addresses the underlying psychological conflicts. Clinicians should also be advised that too rapid weight gain may cause dangerous gastric dilatation or precipitate congestive heart failure.

Drug therapy may be useful in some cases. Some clinicians have considered the perceptual and body image disturbances characteristic of anorexia nervosa to be manifestations of psychosis, and chlorproma-zine and similar drugs have facilitated weight gain in some patients. However, it is not clear whether the benefits of such medications result from their anti-psychotic or their sedative effects. Anxiolytics, such as clonazepam, may be helpful in reducing the overwhelming anxiety associated with eating. Recent studies suggest that the serotonin reuptake blockers fluoxetine and clomipramine may help the depression and obsessions associated with anorexia nervosa, however, antidepressants, which have helped some patients, tend to be ineffective until weight loss has been restored. Cyproheptadine, an appetite stimulator and serotonin antagonist, has proved helpful in the treatment of a subgroup of anorexic patients with particularly severe symptoms and a history of birth trauma.

Although psychoanalysis has not been generally effective in the treatment of anorexia nervosa, psychodynamically oriented psychotherapies that provide support to the patient and focus on issues relating to the struggle for autonomy and personal control are often successful. Cognitive behavioral therapy, which challenges irrational beliefs about food, eating, and body size, and teaches patients strategies for reducing anxiety associated with behavioral change, is often effective. Family therapies, which view the symptoms of anorexia nervosa in the context of family structure and dysfunction, are also effective, particularly in the treatment of children, teenagers, and adults still living at home.

To effectively treat anorexia nervosa, biological, psychological, and behavioral changes must all be addressed. Effective treatment programs should not be welded to any single approach. Clinicians should be familiar with various methods of treatment and use them singly or in combination as called for.