Management and treatment
When considering the management and treatment of anorexia nervosa a multi-professional strategy must be adopted. The individual may require physical therapy for complications of their eating disorder, psychological therapies such as CBT, psychopharmacological intervention for associated depressive symptoms and family therapy to repair damage to relationships. There may also be issues around supporting the carer and certainly there are information needs in close family members or carers in different contexts. Central to interventions is obviously the patient, the consent to involvement of others is vital; however with the inherent ambivalence and risk of denial of the problem, the healthcare professionals need to tread carefully.
In children and adolescents family therapy tends to be a key intervention. There is however a poor evidence base to this, and indeed, other interventions in this condition. The availability of specialist child and adolescent services is variable, however if available family interventions dealing with eating behaviour have some evidence base. Specialist services may offer cognitive behavioural therapy, psychodynamic psychotherapy, motivational enhancement therapy and other family interventions.
The initial aim of psychological intervention must be to engage the patient in that intervention. The denial of a problem and the ambivalence to health care exhibited in this condition is a barrier that must be overcome before psychological intervention can work. Healthcare professionals must build a relationship based on trust and empathy with the patient, their carers and their family as appropriate. There must be an ethos of collaboration with the patient and the patient needs to engage with the process in the same spirit. This engagement may wax and wane with time, the therapist must be sensitive to this, gaining small victories where possible.
In general the aim of the interventions are to promote healthy eating and weight gain, to reduce the impact of other eating disorder related psychological issues and in this way promote psychological recovery. In the context of the patient who has gained weight following a period of hospitalisation the aim of intervention is to maintain the weight gained. In the proportion of patients that go on to develop chronic anorexia nervosa the goals of treatment with psychological intervention may differ, and improvement in the quality of life and maintenance of a safe weight may be paramount.
The evidence base suggests the psychological intervention is poor, family therapy in adolescence has some evidence to support its use however other interventions show variable results.
No drug therapy has been shown to alter the course of anorexia nervosa unless there is co-morbid depression or OCD. Antidepressants and antipsychotics risked doing harm specifically by prolonging the QT interval, evidence of benefit is minimal.
Hospital admission is required when the weight or biochemical disturbances place the patient at risk. Detention under the mental health act is occasionally required and forced feeding is reserved as a last resort. Useful weight gains can be made in hospital under supervised conditions and it also gives the opportunity for intense psychological intervention.
NICE clinical practice recommendations in anorexia nervosa
- In most patients with anorexia nervosa an average weekly weight gain of 0.5 to 1 kg in inpatient settings and 0.5 kg in outpatient settings should be an aim of treatment. This requires about 3500 to 7000 extra calories a week.
- Regular physical monitoring and in some cases treatment with a multivitamin/multi-mineral supplement in oral form is recommended for people with anorexia nervosa during both inpatient and outpatient weight restoration.
- Health care professionals should advise people with eating disorders and osteoporosis or related bone disorders to refrain from physical activities that significantly increase the likelihood of falls. In children and adolescents with eating disorders, growth and development should be closely monitored. Where development is delayed or growth is stunted despite adequate nutrition, paediatric advice should be sought.
- Nasogastric feeding can confer some benefit in terms of increased rate of weight gain or actual weight gain, as part of a treatment programme. There was insufficient evidence that either TPN (total parenteral nutrition) or zinc supplementation confer any benefit in terms of weight gain.
- TPN appears to be associated with more adverse events in one small study. Some limited benefit, on symptoms but not on weight gain, has also been identified from one small trial investigating massage.