Treatment of anorexia nervosa is complex. The Academy for Eating Disorders observes that patients usually need a "treatment team" which may include a primary care physician (pediatrician or adolescent medicine specialist if she is young), psychotherapist, nutritionist, and other health care professionals. Anorexia Nervosa and Related Eating Disorders, Inc. (ANRED) notes that dental work may be required to repair tooth damage and minimize future problems. Teeth of binge/purgers are often injured by over-exposure to stomach acid from frequent vomiting.
The Academy recommends that providers treating all forms of anorexia consult the American Psychiatric Association's Practice Guidelines for Eating Disorders, Am. J. Psychiatry 150, 207-227 (1993). An updated version of the Guidelines will be published shortly. According to the Academy, treatment should be conducted in the least restrictive setting that ensures the patient's safety.
It is crucial to recognize that treatment of the psychological problems underlying anorexia cannot begin until near-normal weight levels are obtained.1 When emaciated, the anorexic's thought processes are distorted by the biological effects of starvation.2 Hilde Bruch, M.D. says: "In this state, patients are not only unwilling to talk about what they feel, but they are actually not able to because they are almost in a toxic state. Meaningful information about their psychological plight can be expressed only after nutrition has improved and when they are far along in treatment."3 According to Dr. Bruch, psychotherapy will not be effective until the patient has reached a threshold weight of 90-95 pounds.4
The Academy notes that the following outpatient psychotherapeutic treatments have been employed with demonstrated effectiveness: cognitive-behavioral therapy, interpersonal psychotherapy, family therapy, and behavior therapy. Behavior therapy employs a system of rewards and punishments to modify maladaptive lifestyles. Cognitive-behavioral therapy employs similar techniques, while adding imagery and fantasy. Interpersonal psychotherapy encompasses a wide variety of "talk" treatments involving two or more people. Family therapy treats familial units instead of individuals. For more detailed definitions, see Reber, Dr. Arthur S., Dictionary of Psychology (Penguin 1985).
The length of therapy required varies greatly, depending on method and practitioner. According to the National Association of Anorexia Nervosa and Associated Disorders (ANAD), family therapy, as practiced by Salvador Minuchin at the Philadelphia Child Guidance Center, lasts approximately six months. Italian researcher Mara Selvini Palazzoli uses team-based, ten-session family therapy on girls between the ages of 13 and 16. She reports a 100 percent cure rate. Dr. Minuchin claims an 85% success record. Dr. Bruch notes improvement in patients after two to three years of psychotherapy.
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