Anorexia Nervosa. Treatment

Anorexia Nervosa. Treatment. Introduction

In anorexia nervosa, extreme fear of weight gain is apparent, leading to an intense focus on body weight. It becomes the central point of their feelings, thoughts, and actions. where extreme thinness or even cachexia is misperceived. Parts of the body are often seen as too fat, with massive overestimation of their size.

The central theme for anorexic patients is the desire for extreme thinness, paired with a wish for self-determination. The patient is desperate to protect her autonomy. She can also use the illness to reduce fears of physicality and the expectations placed on her as an adult woman.

Patients typically have little insight into their condition and deny the dangers it poses. Socially, they often avoid eating in the presence of others, which leads to withdrawal from social life, as most gatherings involve food. Publicly avoiding food is often accompanied by secretly hoarding or discarding it.

ICD-10 and DSM-5 Definition of Anorexia Nervosa

ICD-10: F50.0 Anorexia Nervosa
DSM-V: 307.1 Anorexia Nervosa

An endocrine disorder affecting the hypothalamic-pituitary-gonadal axis, manifesting in women as amenorrhea and in men as loss of libido and potency. An exception is the persistence of vaginal bleeding in anorexic women undergoing hormone replacement therapy. Furthermore other hormonal imbalance such as elevated growth hormone, increased cortisol levels, changes in peripheral thyroid hormones can appaer. When anorexia starts before puberty, there is a delay or suppression of pubertal development.

Types of Anorexia Nervosa

In post-menarchal women, there is an absence of at least three consecutive menstrual cycles (amenorrhea is assumed even if menstruation occurs after hormone administration, such as estrogen).

Specification of type:

• Restrictive Type (F50.00): During the current episode of anorexia nervosa, the person has not engaged in regular “binge eating” or shown “purging” behaviors (such as self-induced vomiting or misuse of laxatives, diuretics, or enemas).
• Binge-Eating/Purging Type (F50.01): During the current episode of anorexia nervosa, the person has regularly experienced binge-eating and shown purging behaviors.

Diagnostic Criteria for Anorexia Nervosa

Anorectic patients have a body image distortion characterized by a specific psychological disorder: the deep-rooted fear of becoming fat exists as an overvalued idea. Patients set an unusually low weight threshold for themselves. They refuse to maintain the minimum normal body weight for their age and height, with weight at least 15% or a BMI of 17.5 or less is expected.

Patients experience extreme fear of gaining weight or becoming fat, even when already underweight. There is a disturbance in how they perceive their body size and weight, with an exaggerated influence of body weight or shape on self-evaluation, or a denial of the severity of their current low weight.

Weight loss is self-induced through the avoidance of high-calorie foods and one or more of the following:

• Self-induced vomiting
• Self-induced use of laxatives
• Excessive physical activity
• Use of appetite suppressants and/or diuretics

Treatment of Anorexia Nervosa

The treatment of Anorexia Nervosa requires multimodal approach because of the complex interaction of physical and psychological symptoms. Body image perception doesn’t change overnight. The treatment concept includes normalizing eating behaviour, weight rehabilitation, and psychotherapy. Involving the family is often helpful, and for young minors, it’s essential.

There is no specific medication for anorexia itself, but pharmacotherapy may help manage certain symptoms, such as severe restlessness. In some cases, treatment with Fluoxetine can be helpful. However, medication should be used to treat psychiatric comorbidities, such as depression or anxiety.

The core of anorexia treatment is psychotherapy. It aims to prevent further conditions like depression or anxiety disorders. Success in psychotherapy requires the patient’s willingness and long-term commitment. Addressing problematic behaviour patterns and personal issues is challenging but offers a path to positive growth, greater self-determination, and renewed joy in life.

Goals in Treatment of Anorexia

At the beginning of treatment, individual goals are discussed and established with patients, based on their personal life circumstances. In addition to the personal objectives, treatment should generally aim to:

• Restoring a healthy body weight and rehabilitating physical effects
• Improving illness awareness and boosting motivation to overcome the disorder
• Educating and advising on healthy nutrition and eating habits
• Changing body perception, attitudes, and feelings about the eating disorder
• Managing psychological difficulties
• Involving the family (support, education, counselling, and therapy)
• Preventing relapse

Symptom resolution often occurs only after extended therapeutic work. The focus should not be on deficits but rather on patient resources—highlighting healthy aspects and skills within their personal context. Approaches solely targeting symptom elimination typically lack long-term success. Since the goal is to foster autonomy and reduce external control, treatment should minimize outside regulation. For this reason, diets with strict eating regimens are not recommended.

Hospitalization in Severe Cases of Anorexia

In cases of life-threatening underweight, rapid weight loss, or severe physical complications, inpatient admission may be required, even against the patient’s will. This also applies to serious psychiatric conditions and risk of suicide or severe self-harm.

Inpatient therapy is also more effective than outpatient strategies because meals are directly supervised by professionals. Additionally, it is more structured and allows for holistic treatment of the disorder.

Involvement of the Family

Where possible and considering existing social interactions, involving the family is a key pillar of anorexia treatment and can provide significant support. Family therapy isn’t always necessary, but simply reassuring parents that the cause is often multifaceted and not their fault can be helpful. The family can contribute a lot to overcoming the illness.

Improving Self-Esteem and Social Skills

A core element of psychotherapy includes cognitive-behavioral therapy (CBT). Patients are encouraged to challenge dysfunctional thoughts linked to eating disorders. A major focus is on how the patient views their body and weight, which deeply impacts self-esteem. Existing beliefs are questioned, and new, reality-based thoughts are developed.

Depending on individual needs, creative therapy, animal-assisted therapy, mindfulness, body image group work, and social-pedagogical planning may be included. Before discharge, stress tests, such as therapeutic leave to the patient’s home environment, are crucial to practice applying clinic-learned skills in daily life and build confidence for the future.

Weight Improvement and Nutritional Therapy

A key focus of therapy is treating physical damage and normalizing weight. A steady, not too rapid, weight gain is crucial for the body to properly utilize the nutrients. Rapid weight gain can be harmful and increase the risk of immediate relapse. It’s believed that fast weight gain might be an unconscious defense mechanism, with the patient addressing issues only on a surface level, not emotionally. Weight gain is supported by meal plans, nutritional counseling, and portion guides, transitioning to self-management.

The aim is to achieve a weight gain of 0.3 to 1 kg per week (in inpatient settings) to reach a weight at which menstruation resumes. The target weight often aligns with the 25th BMI percentile, as this is generally when menstruation is expected to return. Weight is typically monitored one to two times per week. Most physical symptoms improve once malnutrition is corrected.

To normalize eating behavior, the following measures are offered as part of nutritional therapy:

• Comprehensive counseling on balanced nutrition
• Creation of a structured meal plan with main meals and snacks, gradually introducing calorie-dense foods that were previously avoided
• Group activities such as cooking together and “model meals” under supervision.

Psychotherapy Used in Treatment of Anorexia Nervosa

The main methods used for treating Anorexia Nervosa are: cognitive behavioral therapy (CBT) and depth psychology-based psychotherapy (also called psychodynamic therapy). Analytical psychotherapy (psychoanalysis) is applied for patients with chronic, deep-rooted issues needing long-term treatment. Other evidence based method in treatment of Anorexia Nervosa are: Interpersonal Therapy and Systemic Family Therapy.

Systemic family therapy plays a key role in treating children and adolescents, where involving parents and siblings is vital. It addresses family problems and works on solutions for everyone.

Cognitive Behavioral Therapy (CBT)

In CBT, mental disorders are viewed as consequences of negative or stressful learning experiences. It is believed that problematic behaviors related to mental disorders can be unlearned through new experiences. CBT aims to stimulate both conscious and unconscious learning processes, reducing problematic behaviors and symptoms. Therapy focuses on specific eating-related issues like irregular meal patterns or avoidance of certain foods. Normal eating habits are reinforced through structured meal plans and eating diaries. CBT also questions how weight and body image affect self-perception, aiming to change distorted self-perception and unhealthy attitudes. The goal is to improve self-esteem, conflict resolution skills, and social competence.

Depth Psychology-Based Psychotherapy

In this approach, eating disorders are seen as expressions of internal and interpersonal conflicts that stem from life experiences. Understanding these conflicts and their underlying causes helps to find healthier solutions. Life experiences often emerge in the therapeutic relationship and are processed with the therapist. This creates opportunities for new, healing experiences, allowing the symptom (the eating disorder) to no longer be needed as a solution for inner conflicts.

Analytical Psychotherapy

This approach can last several years and aims to bring about profound and healing personality changes.

Interpersonal Therapy

This method focuses on improving current life situations, such as resolving interpersonal conflicts or navigating transitions, like becoming an adult or moving from school to work.

Systemic Family Therapy

Involving parents and siblings in therapy is crucial, especially for younger patients. Family issues are explored, and solutions are developed for everyone involved. Changes in family dynamics can lead to positive outcomes for the patient, while family members can also benefit from the therapy. For example, parents’ guilt, which they often carry, can be alleviated.

Therapy Conditions and Treatment Duration

Due to illness-related denial, therapy conditions must be clearly defined and monitored. For lasting recovery, outpatient psychotherapy is crucial after acute treatment or hospital discharge, typically after 6 weeks to 3 months, depending on severity. Participation in self-help groups is also recommended.

Etiology of Anorexia Nervosa

The following functional characteristics are important for the development and maintenance of anorexia:

• Achieving autonomy, primarily by breaking free from the strong attachment to the family and distancing from parental values and expectations.
• Developing self-confidence and self-esteem
• A cry for help seeking love, security, and recognition
• Protection from the demands of adult life
• Maintaining family homeostasis

Models for the Development of Anorexia

The models for understanding anorexia are based on various functional aspects:

Anorexia as Defense Against Sexual Desires

One psychoanalytic drive-theory model views anorexia as a defense against sexual desires, a way to end the psychosexual crises of puberty and return to the seemingly idealized world of childhood. Sexual impulses are either not perceived or are associated with fear. As evidence for this theory, it is pointed out that weight loss largely strips the body of secondary sexual characteristics, reducing sexual signaling, and menstruation stops.

Anorexia as Protection of Individual’s Autonomy

Another model sees anorexia as a battle for intrapsychic and interpersonal self-assertion. The anorexic symptoms highlight the struggle for identity and control over one’s life. Often overly compliant in childhood, these individuals feel powerless over their own lives. By controlling their bodies and overcoming hunger, anorexic patients experience themselves as independent. This narrow focus on control and self-determination explains the overwhelming importance of body weight.

Anorexia as Compromise Protecting Family Harmony

A third model emphasizes an interactional or family-dynamic perspective. The family systems of anorexic men and women always show distinctive patterns. Anorexia is more common in “closely bound” families, characterized by a strong drive for harmony, an idealization of family unity, the suppression of personal needs, and a willingness to sacrifice. In this atmosphere, “temptations,” such as those posed by sexuality or food, must be rejected.

Anorexia and Family Dynamics

Anorexic women and men serve an important role as symptom bearers in maintaining family cohesion and diffusing tensions and conflicts. Parental disputes and the crossing of generational boundaries place familial responsibilities on the child, intensifying their ambivalence about growing up. Moreover, families of anorexic patients often exhibit high performance demands, rigid justice, and strong moral orientation, which prevent them from exploring adulthood.

The Communication Theory

Analysis from the perspective of the communication theory on different communication styles in anorexic patients according to the family dynamics:

• The first communication strategy is “denial.” In families as described above, conflicts are avoided and swept under the rug. Anorexia perfects this denial by diverting attention from existing problems, which seem to lose importance in the face of the illness.

• The second faulty solution involves developing “utopian expectations.” Anorexic women believe that by being thin, all life problems will be solved. Once they are thin, they mistakenly think, all other difficulties will disappear.

• The third contra productive communication solution involves creating “paradoxes.” One such paradox is closely related to the symptom: anorexic women rigorously reject food, yet obsess over it constantly. They reject their bodies but focus all thoughts and actions on them. They fear normalcy, mediocrity, yet are terrified of standing out. They have a deep fear of separation but are also afraid of closeness, particularly intimate or sexual closeness. These paradoxes are rooted in the equally paradoxical parental message to remain a child while also being an independent adult.

Physical Complications of Anorexia Nervosa

Despite malnutrition and low body weight, anorexic patients are often surprisingly “healthy.” This is due to the body’s remarkable ability to adapt its metabolism. However, severe damage related to anorexia can still occur.

Anorexia nervosa is regularly associated with endocrine abnormalities, leading to amenorrhea in women. Additionally, changes in peripheral thyroid hormone metabolism and elevated growth hormone and cortisol levels are observed. It remains unclear whether these abnormalities are part of the underlying anorexic disorder or consequences of malnutrition.

Complications in the field of general medicine:

• Cachexia
• Hypothermia
• Bradypnea
• Acrocyanosis
• Sleep disorders
• Osteoporosis

Internal medicine:

• Cardiovascular changes/heart atrophy with bradycardia and hypotension
• Slowed heart rate, which can lead to dizziness and fainting spells
• Low pulse rate
• Kidney damage
• Hematological dysfunction with anemia and leukopenia
• Reduced kidney concentration ability with polyuria, potentially leading to kidney failure
• Susceptibility to infections
• Immune dysfunction with reduced T-cell function and decreased macrophage phagocytosis
• Gastrointestinal changes
• Electrolyte imbalances
• Peripheral edema

Dermatology:

• Atrophic, dry skin
• Yellowish skin tone
• Hair loss
• Lanugo hair growth
• Superficial scars on the back of the hand
• In extreme cases, bedsores
• Brittle fingernails and toenails
• Clubbed fingers

Dentistry and ENT (ear, nose, throat):

• Tooth enamel erosion due to frequent vomiting
• Painless swelling of the parotid gland due to frequent vomiting

Endocrinology and Gynecology:

• Elevated adrenaline levels
• Amenorrhea
• Altered peripheral thyroid hormone metabolism
• Increased growth hormone and cortisol levels

Chronicity and Mortality

Reliable data on the chronicity and mortality of the disorder is difficult to obtain due to numerous methodological issues. The often spectacular and bizarre nature of the disorder can lead to an overemphasis on its danger. According to solid studies, at least half of all patients fully recover, while an additional 30% recover enough to lead mostly normal lives despite the illness.

Reports on mortality rates are highly variable, with an average of 5.5%, ranging from 0% to 21%. In more than half of published studies, the mortality rate is 4% or lower. Particularly in older follow-up studies, mortality rates around 20% may be partly due to iatrogenic factors related to inappropriate treatment.

Anorexia Nervosa. Summary

In anorexia nervosa, extreme fear of weight gain is apparent, leading to an intense focus on body weight. It becomes the central point of their feelings, thoughts, and actions. They perceive their body or certain parts as too fat, often grossly overestimating it. Typically, low weight in anorexia nervosa is mainly achieved and maintained through starvation and food refusal.

There is usually little insight into the anorexic condition, and the associated dangers are denied. Socially, it causes problems because sufferers prefer to avoid eating in the presence of others. This leads to withdrawal from many aspects of social life, as most forms of socializing involve food in some way. Avoiding public eating often coincides with secretly hoarding or throwing away food.

Interestingly, anorexic women and men often enjoy food preparation, collecting recipes, reading cookbooks, and cooking lavish meals for others. Anorexic girls and women are frequently described as former “perfect children,” who excelled at everything. In this way, they typically met the expectations of the achievement-oriented middle-class backgrounds they come from.