What are the aims of the treatment?
Does treatment work? - What the research says
How is nutrition restored?
What psychological treatments are available?
Medication for anorexia and the treatment of co-morbidity
Treatment for women's health issues
Beyond symptom control to social adjustment
Are self help groups going to help me get better?
This section describes treatments and summarises what is known about their effectiveness and their role at particular stages of the illness. Research has not yet found any cure. However, just because there is no proof about whether or not a treatment works, doesn't mean it should not be tried. It may be that it does work and there just hasn't been enough research of the sort that gives us proof.
What are the aims of treatment?The aims of treatment for anorexia nervosa include to:
- Prevent death by restoring nutrition
- Correct dysfunctional behaviours and thinking
- Treat depression and obsessional thinking
- Prevent or reduce absences from work or school
- Resume normal psychological and physical development
- Restore autonomy and prevent relapse and disablement
- Support family or partner where needed. Top of page
Does treatment work? - What the research saysBecause anorexia nervosa is rare, only small numbers of people participate in research. This means that it is often hard to prove that psychological treatments work. Because of its seriousness, it is also unethical to test one group in treatment against another which is denied treatment. The research then has many limitations and can only tell us the following:
- No specific treatment is known to be effective (as a cure) but some new research is promising
- Research shows that the earlier treatment is started the more chance there is of recovery, and
- Alternative treatments and natural remedies have not been researched enough to advise on their role.
How is nutrition restored?Restoring nutrition by getting you to eat sufficiently is a non-negotiable aspect of treatment. Every effort is made to help you do this yourself. A diet high in proteins, carbohydrates and fats is used and is best supervised by a dietician.
If food is refused, balanced food substitutes are used. But this is generally avoided because the key goal is to get you to eat normal foods again. Generally, re-feeding through a nasal tube is only used in an emergency and is not recommended. Instead, psychologists will design a behaviour program to help you overcome your fears about eating.
Restoring normal nutrition is essential for recovery, but on its own is not enough to prevent relapse. Psychological change is also needed. Figure 1 shows the goals of psychological treatment and the treatment process.
Figure 1: Some goals of psychological treatment and the treatment process
Research has not yet unearthed a cure.
Your responsibilities in treatment may include keeping appointments; asking for information you need; and treatment planning.Top of page
What psychological treatments are available?Because there is no proof of any treatment being the best, it is important to discuss all options with your key health professional to see if they apply in your case. Different treatments have very specific roles and the appropriate treatment will depend on the severity of illness and your stage of treatment or recovery. These are the main psychological treatments that have been evaluated:
Supportive psychotherapyThis is counselling conducted by either a medical or non-medical professional. It is 'supportive' in that it discusses with you your experiences of anorexia with respect, care and consistency to guide you to recovery without attempting to change your basic personality. Supportive listening to your experience and its emotional impact is a key component. Research and consumer feedback deem this treatment to be helpful.
Psycho-educationThis term really just means getting information and education about anorexia and other mental health issues as well as information about the treatments and their purpose. It is based on listening to your information needs and readiness and helping you take charge of your health through being fully informed.
Cognitive behavioural therapy (CBT)This psychological treatment can be done by medical or non-medical staff. It is usually performed by specially trained psychologists and involves looking at how you think and how thought shapes behaviour. It tries to get you to modify your behaviour by adopting more helpful thinking patterns. Modifying anxiety about foods and beliefs about weight is a key focus. CBT is also used for depression where the focus is to change negative perceptions about events in your life, which may contribute to lowered mood.
Interpersonal therapyThis short term therapy has a role to play if a person with anorexia has identified relationships as a problem. Relationships are often strained with anorexia. You are taught to approach relationship issues differently. While it is not proven to 'treat' anorexia specifically, it has been shown to reduce depression, which often exists with anorexia.Top of page
Psychodynamic oriented psychotherapyThis approach is similar to interpersonal therapy but is often long term, focussing on past patterns of emotion and relating. It is of unproven usefulness.
Narrative therapyThis approach helps the person to view anorexia as an external problem affecting their life story, and not one about the true self. The person is encouraged to change their life story by defeating anorexia and its negative messages and impacts.
Family therapyThere are many different kinds of family therapy and it can be provided by social workers, psychologists, psychiatrists or nurses. Because anorexia can run in families and can impact on whole families, it tries to maintain relationships and support from the family for the person with anorexia. It helps the whole family in a group. It is considered very appropriate for children and adolescents with anorexia and there is research evidence to support its value for those under 19 years of age.
Motivational enhancement therapyThere is emerging interest in the application of motivational interviewing to the treatment of anorexia.
This approach has been evaluated as useful in the treatment of alcohol and drug addiction because its focus is upon your readiness and/or resistance to change. The therapist gives you feedback on the stage of readiness to change that you are at, and tailors treatment advice to that stage. He or she helps to motivate you along a process whereby you judge for yourself the benefits and drawbacks of change and prepare for those benefits or drawbacks. Direct confrontation is avoided. The stages of change are:
- action, and
Medication for anorexia and the treatment of co-morbidityUnlike antidepressants, or anti-psychotics, there is no anti-anorexia medication that is specifically designed to treat anorexia. However, medications have been found to be useful for treating some of the conditions that occur with anorexia. 'Co-morbidity' means that one or more illnesses are present at once. For example, anxiety and depression are both common in anorexia. Although there is no firm evidence that antidepressants are effective against the depression of anorexia nervosa, if an antidepressant is used, Selective Serotonin Reuptake Inhibitors (SSRIs) are a preferred type because they are safer for your heart.
Being prescribed anti-psychotic medication need not mean that you have psychosis, or that you are going 'crazy'. They are sometimes used because they can also reduce anxiety without the risk of addiction, whereas many anti-anxiety medications risk addiction. Examples of anti-psychotic medications include:
- Chlorpromazine (Largactil)
- Thioridazine (Aldazine and Melleril)
- Olanzapine (Zyprexa).
Obsessional symptoms are often the focus of treatment. Recent reports suggest that some people benefit from a drug called olanzapine used to treat this symptom.
Always discuss side effects with your doctor. A book called 'MIMS' will list all known side effects of medication. Top of page
Treatment for women's health issuesAnovulation (not ovulating in women) should not be treated except by restoring nutrition. Hormone Replacement Therapy (HRT) or similar treatments are generally not advised for women with anorexia.
Women with anorexia are likely to have complicated pregnancies and can have premature and unhealthy babies. Parenting skills can also be complicated if the anorexia is unresolved. Most mental health services can provide early intervention and parenting support to help new parents develop these skills.
Low bone density and insufficient calcium is a common health issue for women. It is severely aggravated by anorexia nervosa. The only sure way to restore bone density is by nutritional restoration. Calcium supplements are harmless but of little use and HRT is of unproven use. Recently, bisphosphanates have been used in people with chronic anorexia, but their long-term effects are unknown.
Beyond symptom control to social adjustmentCoping with anorexia is discussed in detail in Section 2. However, it is important to note that once you start to gain weight again, the road to recovery is only just beginning and this is a time when treatment is showing signs of working and must continue. Treatment aims to help you get the physical, behavioural and emotional symptoms of anorexia under control and manage the complications of weight loss, but thereafter, it helps you to rebuild a life which is as normal as possible, despite living with anorexia. This is called maintenance and relapse prevention stages of treatment, and are critical to ultimate recovery. It involves ongoing contact with your key health professional in regular psychotherapy and medical monitoring as needed.Top of page
Are self help groups going to help me get better?'Treatment', including that provided in groups, is usually differentiated from 'support' of the kind offered by self help and mutual support groups. Mutual support and self help groups are usually considered to add value to treatment rather than replace it or be a treatment in their own right. No controlled trials were found evaluating them in anorexia nervosa.
Non-government organisations of people having recovered from anorexia and their families provide referral, information, telephone support and individual advice. Many also provide self help or support groups. Services vary from place to place with different philosophies and different structures. Some groups have professionals acting as the group facilitator, while others provide self-advocacy or self help groups without professionals participating.
It is not known which type of self help or support group is the more effective. However, most agree that they may help in the following ways:
- To guard against total social isolation where no other support is available
- To help persuade a person to seek assessment and treatment
- To provide encouragement to stay in treatment
- To provide information about what to expect from treatment
- To provide support to families and friends
- To provide free services to those awaiting access to treatment.