Treatment of Anorexia Nervosa

Anorexia nervosa is an eating disorder characterized by excessive weight loss, and irrational fear of gaining weight and distorted body self-perception. Anorexia nervosa usually developes during adolescence and early adulthood.Due to the fear of gaining weight, people with this disorder restrict the amount of food they intake. This restriction of food intake causes metabolic and hormonal disorders.The terms anorexia nervosa and anorexia are often used interchangeably, however anorexia is simply a medical term for lack of appetite. Anorexia nervosa has many complicated implications and may be thought of as a lifelong illness that may never be truly cured, but only managed over time. Anorexia nervosa is characterized by low body weight, inappropriate eating and obsession with thin figure.

Anorexia nervosa is often coupled with a distorted self image which may be maintained by various cognitive biases that alter how the affected individual evaluates and thinks about her or his body, food and eating. Persons with anorexia nervosa continue to feel hunger, but deny themselves all but very small quantities of food. The average caloric intake of a person with anorexia nervosa is 600–800 calories per day, but extreme cases of complete self-starvation are known.It is a serious mental illness with a high incidence of comorbidity and similarly high mortality rates to serious psychiatric disorders.[7]

Anorexia most often has its onset in adolescence and is most prevalent among adolescent girls. However, more recent studies show that the onset age of anorexia has decreased from an average of 13 to 17 years of age to 9 to 12. While it can affect men and women of any age, race, and socioeconomic and cultural background,Anorexia nervosa occurs in females 10 times more than in males. While anorexia nervosa is quite commonly (in lay circles) believed to be a woman ‘s illness, it should not be forgotten than ten per cent of people with anorexia nervosa are male.

The term anorexia nervosa was established in 1873 by Sir William Gull, one of Queen Victoria’s personal physicians.The term is of Greek origin: an- (ἀν-, prefix denoting negation) and orexis (ὄρεξις, “appetite”), thus meaning a lack of desire to eat.However, while the term “anorexia nervosa” literally means “neurotic loss of appetite” the literal meaning of the term is somewhat misleading. Many anorexics do enjoy eating and have certainly not lost their appetite as the term “loss of appetite” is normally understood; it is better to regard anorexia nervosa as a self-punitive addiction to fasting, rather than a literal loss of appetite.

Studies have hypothesized that the continuance of disordered eating patterns may be epiphenomena of starvation. The results of the Minnesota Starvation Experiment showed that normal controls exhibit many of the behavioral patterns of anorexia nervosa when subjected to starvation. This may be due to the numerous changes in the neuroendocrine system, which results in a self perpetuating cycle. Studies have suggested that the initial weight loss such as dieting may be the triggering factor in developing AN in some cases, possibly because of an already inherent predisposition toward AN. One study reports cases of AN resulting from unintended weight loss that resulted from varied causes such as a parasitic infection, medication side effects, and surgery. The weight loss itself was the triggering factor

Treatment

Treatment for anorexia nervosa tries to address three main areas. 1) Restoring the person to a healthy weight; 2) Treating the psychological disorders related to the illness; 3) Reducing or eliminating behaviours or thoughts that originally led to the disordered eating. If anorexia nervosa is not treated, serious complications such as heart conditions and kidney failure can initiate and eventually lead to death.

Dietary

  • Zinc supplementation has been shown in various studies to be beneficial in the treatment of AN even in patients not suffering from zinc deficiency, by helping to increase weight gain.
  • Essential fatty acids:The omega-3 fatty acids docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) have been shown to benefit various neuropsychiatric disorders. There was reported rapid improvement in a case of severe AN treated with ethyl-eicosapentaenoic acid (E-EPA) and micronutrients.DHA and EPA supplementation has been shown to be a benefit in many of the comorbid disorders of AN including: attention deficit/hyperactivity disorder (ADHD), autism, major depressive disorder (MDD),bipolar disorder, and borderline personality disorder. Accelerated cognitive decline and mild cognitive impairment (MCI) correlate with lowered tissue levels of DHA/EPA, and supplementation has improved cognitive function.
  • Nutrition counseling
  • Medical Nutrition Therapy;(MNT) also referred to as Nutrition Therapy is the development and provision of a nutritional treatment or therapy based on a detailed assessment of a person’s medical history, psychosocial history, physical examination, and dietary history.

Medication

  • Olanzapine: has been shown to be effective in treating certain aspects of AN including to help raise the body mass index and reduce obsessionality, including obsessional thoughts about food.However, its primary usefulness is that it is one of the most potent appetite stimulants known, and causes the body to preferentially store fat.

Therapy

  • Cognitive behavioral therapy (CBT) CBT is an evidence based approach which in studies to date has shown to be useful in adolescents and adults with anorexia nervosa.Components of using CBT with adults and adolescents with anorexia nervosa have been outlined by several professionals as
  • the therapist focuses on using cognitive restructuring to modify distorted beliefs and attitudes about the meaning of weight, shape and appearance
  • specific behavioral techniques addressing the normalization of eating patterns and weight restorations, examples of this include the use of a food diary, meal plans, and incremental weight gain
  • cognitive techniques such as restructuring, problem solving, and identification and expression of affect
  • When using CBT with adolescents and children with AN, several professionals have expressed concerns about the minimum age and level of cognition necessary for implementing cognitive behavioral techniques.Modified versions and elements of CBT can be implemented with children and adolescents with AN. Such modifications may include the use of behavioral experiments to disconfirm distorted beliefs and absolutistic thinking in children and adolescents.
  • Acceptance and commitment therapy: A type of CBT, has shown promise in the treatment of AN” participants experienced clinically significant improvement on at least some measures; no participants worsened or lost weight even at 1-year follow-up.”
  • Cognitive Remediation Therapy (CRT): is a cognitive rehabilitation therapy developed at King’s College in London designed to improve neurocognitive abilities such as attention, working memory, cognitive flexibility and planning, and executive functioning which leads to improved social functioning. Neuropsychological studies have shown that patients with AN have difficulties in cognitive flexibility. In studies conducted at Kings College[197] and in Poland with adolescents CRT was proven to be beneficial in treating anorexia nervosa,[197] in the United States clinical trials are still being conducted by the National Institute of Mental Healthon adolescents age 10–17 and Stanford University in subjects over 16 as a conjunctive therapy with Cognitive behavioral therapy.
  • Family therapy: The most effective form of therapy for adolescents with anorexia is family therapy.There are various forms of family therapy that have been proven to work in the treatment of adolescent AN including “conjoint family therapy” (CFT), in which the parents and child are seen together by the same therapist, “separated family therapy” (SFT) in which parents and child attend therapy separately with different therapists. “Eisler’s cohort show that, irrespective of the type of FBT, 75% of patients have a good outcome, 15% an intermediate outcome… “.Proponents of Family Therapy for adolescents with AN assert that it is important to include parents in the adolescent’s treatment.Several components of using Family Therapy with Children and Adolescents are:
  • the family is seen as a resource for the adolescent
  • anorexia nervosa is reframed in benign, non blaming terms
  • directives are provided to parents so that they may take charge of their child or adolescent’s eating routine
  • a structured behavioral weight gain program is implemented
  • after weight gain, control over eating is gradually returned to the child or adolescent
  • as the child or adolescent begins to eat and gain weight, the theraputic focus broadens to include family interaction problems, growth and autonomy issues and parent child conflicts
  • Maudsley Family Therapy: A 4 to 5 year follow up study of the Maudsley approach, a manualized model, that shows full recovery at rates up to 90%.

Alternative medicine

  • Yoga: In preliminary studies indivualized yoga treatment has shown positive results for use as an adjunctive therapy to standard care. The treatment was shown to reduce eating disorder symptoms, including food preoccupation, which decreased immediately after each session. Scores on the Eating Disorder Examination decreased consistently over the course of treatment.[

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