Anorexia nervosa typically begins between 14 and 18 years of age. In the early stages, clients often deny they have a neg-ative body image or anxiety regarding their appearance. They are very pleased with their ability to control their weight and may express this. When they initially come for treatment, they may be unable to identify or to explain their emotions about life events such as school or relationships with family or friends. A profound sense of emptiness is common.
As the illness progresses, depression and lability in mood become more apparent. As dieting and compulsive behaviors increase, clients isolate themselves. This social isolation can lead to a basic mistrust of others and even paranoia. Clients may believe their peers are jealous of their weight loss and may believe that family and health care professionals are trying to make them “fat and ugly.”
In long-term studies of clients with anorexia nervosa, Anderson and Yager (2005) reported that 30% were well, 30% were partially improved, 30% were chronically ill, and 10% had died of anorexia-related causes. Clients with the lowest body weights and longest durations of illness tended to relapse most often and have the poorest out-comes. Clients who abuse laxatives are at a greater risk for medical complications. Table 18.2 lists common medical complications of eating disorders.
Clients with anorexia nervosa can be very difficult to treat because they are often resistant, appear uninter-ested, and deny their problems. Treatment settings include inpatient specialty eating disorder units, partial hospitalization or day treatment programs, and outpa-tient therapy. The choice of setting depends on the sever-ity of the illness, such as weight loss, physical symptoms, duration of binging and purging, drive for thinness, body dissatisfaction, and comorbid psychiatric conditions. Major life-threatening complications that indicate the need for hospital admission include severe fluid, electro-lyte, and metabolic imbalances; cardiovascular complica-tions; severe weight loss and its consequences (Andreasen
Black, 2006); and risk for suicide. Short hospital stays are most effective for clients who are amenable to weight gain, and gain weight rapidly while hospitalized. Longer inpatient stays are required for those who gain weight more slowly and are more resistant to gaining additional weight (Thiels, 2008). Outpatient therapy has the best success with clients who have been ill for fewer than 6 months, are not binging and purging, and have parents likely to participate effectively in family therapy. Cognitive behavior therapy can also be effective in preventing relapse and improving overall outcomes.
Medical management focuses on weight restoration, nutri-tional rehabilitation, rehydration, and correction of elec-trolyte imbalances. Clients receive nutritionally balanced meals and snacks that gradually increase caloric intake to a normal level for size, age, and activity. Severely malnour-ished clients may require total parenteral nutrition, tube feedings, or hyperalimentation to receive adequate nutri-tional intake. Generally, access to a bathroom is supervised to prevent purging as clients begin to eat more food. Weight gain and adequate food intake are most often the criteria for determining the effectiveness of treatment.
Several classes of drugs have been studied, but few have shown clinical success. Amitriptyline (Elavil) and the anti-histamine cyproheptadine (Periactin) in high doses (up to 28 mg/day) can promote weight gain in inpatients with anorexia nervosa. Olanzapine (Zyprexa) has been used with success because of its antipsychotic effect (on bizarrebody image distortions) and associated weight gain. Fluoxetine (Prozac) has some effectiveness in preventing relapse in clients whose weight has been partially or com-pletely restored (Andreasen & Black, 2006); however, close monitoring is needed because weight loss can be a side effect.
Family therapy may be beneficial for families of clients younger than 18 years. Families who demonstrate enmesh-ment, unclear boundaries among members, and difficulty handling emotions and conflict can begin to resolve these issues and improve communication. Family therapy also is useful to help members to be effective participants in the client’s treatment. However, in a dysfunctional family, significant improvements in family functioning may take 2 years or more.
Individual therapy for clients with anorexia nervosa may be indicated in some circumstances; for example, if the family cannot participate in family therapy, if the client is older or separated from the nuclear family, or if the cli-ent has individual issues requiring psychotherapy. Therapy that focuses on the client’s particular issues and circum-stances, such as coping skills, self-esteem, self-acceptance, interpersonal relationships, assertiveness, can improve overall functioning and life satisfaction. Cognitive– behavioral therapy (CBT), long used with clients with bulimia, has been adapted for adolescents and used successfully (Schmidt, 2008).