Anorexia Nervosa: Opportunities and Challenges in Treatment

Abstract

Anorexia nervosa is an eating disorder condition characterized by an abnormal fear of gaining weight, driving people to starve themselves and become dangerously thin. It involves restricting food intake, which can lead to severe nutritional deficiencies. Anorexia nervosa can affect people of all ages, genders, races and ethnicities. The effects of anorexia nervosa can be life threatening, but counseling and treatment for underlying mental health issues can help people with this condition. Goals of treatment include restoring the person to a healthy weight, treating emotional issues such as low self-esteem, correcting distorted thinking patterns, and developing long-term behavioral changes. Early diagnosis and treatment are more likely to lead to a positive outcome. The physical signs and symptoms of anorexia nervosa are related to starvation. Anorexia also includes emotional and behavioral issues involving an unrealistic perception of body weight and an extremely strong fear of gaining weight or becoming fat. This chapter aimed to understand the opportunities embedded and challenges encountered in the treatment of anorexia nervosa. Information given will assist the patient and team of professionals (primary care physician, mental health professionals, nutritionist, counselors) in the treatment of this disorder to support recovery and prevent relapse.

1. Introduction

Anorexia nervosa is an eating disorder condition portrayed by an abnormal fear of gaining weight this drives people to starve themselves and eventually become dangerously thin [1]. It is more prominent in females but can also be found in males, a life change or traumatic event may be associated with the development of the illness and a desire to excel in sports is a contributing factor [2].

Dieting behavior in anorexia nervosa is associated mostly by an intense fear becoming obese or gaining excess weight. Individuals with anorexia will say they want and are willing to gain weight; their behavior (action) is not in line with their intention. For instance, they consume minute amounts of low-energy giving foods and engaged in physical exercise beyond the usual. Also, persons with anorexia nervosa intermittently engage in binge eating and purge by vomiting or misuse of laxative. Anorexia nervosa is of two types:

• Restricting type, in this type individuals lose weight primarily by dieting, fasting or exercising excessively [3].

• Also, Binge – eating or purging type in which persons also engage in intermittent binge eating and purging behaviors.

The risk of evolving anorexia nervosa is greater in models, dancers, and athletes in sports where appearance and weight are important, especially among wrestlers, boxers, gymnast, and figure skaters.

People with anorexia tend to be very successful, they perform well in sports, school, work and other activities. They tend to be perfectionists with compulsive, anxious, and depressive symptoms. Most times it begins around the time of puberty, but can also develop at any time.

Over time, some of the following symptoms may develop related to starvation or purging behaviors:

• Menstrual periods cease

• Dizziness or fainting from dehydration

• Brittle hair/nails

Anorexia nervosa is characterized by the individuals’ refusal to maintain adequate weight for their height, refusal to feed associated with distortion of the bodily image, and denial of their pathological condition [4].

People with anorexia find it difficult to recognize that they have a mental illness or psychiatric disorder. This is because it’s hard for them to get out of the habits they have developed as a result of anorexia, to recover usually can take some time. Although people with anorexia respond to treatment, the earlier the treatment begins, the better the chances of a complete recovery. Treatment strategy usually involves talking therapies, which include cognitive behavioral therapy, the aim is to change the person’s thoughts, feelings, and behavior around food. Nutritional support is essential and is offered to help gain weight properly.

2. Causes

The cause of anorexia is currently unknown [1]. Research suggests that a combination of certain personality traits, emotions, and thinking patterns, as well as biological and environmental factors might be responsible [5]. Cultural factors also play a role, where societies that value thinness have higher rates of the disease. Additionally, it can be found among those involved in activities that value thinness, such as high-level athletics, modeling, and dancing [6]. Diagnosis for the disease requires a significantly low weight and the severity of disease which is based on body mass index (BMI) in adults is classified as; mild disease having a body mass index of greater than 17, moderate a body mass index of 16 to 17, severe a body mass index of 15 to 16, and extreme a body mass index which is less than 15. For children, a body mass index for age percentile of less than the 5th percentile is often used [7].

3. Symptoms

The visible manifestation of anorexia nervosa is related to starvation. It includes emotional and behavioral issues encompassing an unrealistic perception of body weight and an extremely strong fear of gaining weight or becoming obese. Many atimes it is difficult to notice signs and symptoms because what is considered a low body weight is different from individual, while some individuals may not appear extremely thin. Also, people with eating disorder often conceal their thinness, eating habits or physical problems.

3.1 Symptoms/signs

Visible signs and symptoms of anorexia include:

• Insomnia

• Dizziness or fainting

• Hair that thins, breaks or falls out

• Thin appearance

• Abnormal blood counts

• Fatique

• Extreme weight loss or not making expected developmental weight gains

• Dizziness or fainting

• Bluish discoloration of the fingers

• Absence of menstruation

• Constipation and abdominal pain

• Intolerance of cold

• Irregular heart rhythms

• Low blood pressure

• Dehydration

• Swelling of arms or legs

4. Behavioral and emotional manifestation

Behavioral symptoms of anorexia include attempting to lose weight through:

• Exercising excessively

• Restricting food severely through skipping meals or fasting

• Binge eating and self-induced vomiting to get rid of food, this include the use of diet aids or herbal products and laxatives.

Emotional signs and symptoms are:

• Frequently skipping meals or refusing to eat

• Preoccupation with food, which sometimes includes cooking elaborate meals for others but not eating them

• Eating only a few certain “safe” foods, usually those low in fat and calories

• Denial of hunger or making excuses for not eating

• Not wanting to eat in public

• Lying about how much food has been eaten

• Fear of gaining weight that may include repeated weighing or measuring the body

• Frequent checking in the mirror for perceived flaws

• Social withdrawal

• Irritability

5. Treatment for anorexia nervosa

Goals of treatment include restoring the person to a healthy weight, treating emotional issues such as low self-esteem, correcting distorted thinking patterns, and developing long-term behavioral changes.

Treatment for anorexia recovery is paramount for person who is dealing with medical complications as a result starvation, such as gastrointestinal distress, cardiovascular disorders such as low blood pressure, dehydration, and more. Psychological complications that would entail higher levels of care include urges to suicidal ideation or self-harm.

For a person recovering from anorexia nervosa and is medically stable, intensive medical intervention might not be necessary. Residential treatment for anorexia nervosa may be an appropriate level of care, this treatment may also be ideal for individual who is recuperating from anorexia nervosa but is mentally retarded and could not respond to partial hospitalization or outpatient treatment. The rehabilitation process for anorexia nervosa is a complex process, residential treatment can be a better choice for a person who is in need of multidisciplinary care for recovery. Treatment options will vary depending on the individual’s needs, treatment most often involves a combination of the following treatment methods:

• Psychotherapy: This involves individual counseling that focuses on changing the thinking (cognitive therapy) and behavior (behavioral therapy). Treatment includes practical techniques for adopting healthy attitudes toward food and weight, as well as approaches for changing the way the person responds to difficult situations.

• Medications: Certain antidepressant medications can be used to help control anxiety and depression associated with eating disorder. Some antidepressants medications also help to improve sleep and stimulate appetite. Other forms medications can be given to help control anxiety and/or distorted attitudes toward eating and body perception.

• Nutrition counseling: This approach has been formulated to teach a healthy pattern to food and weight, to help restore ideal eating patterns, and to evaluate the importance of nutrition and following an adequate diet which is ideal for growth and well-being.

• Group and/or family therapy: Family support is very important for a treatment to be successful. It is important that family members understand the eating disorder and should be able to recognize its physical manifestation. Individuals with eating disorders might benefit from group therapy, where they can find support and care, discuss their feelings and concerns openly with others who also share common experiences and problems.

• Hospitalization: This is essential in order to treat severe weight loss that has resulted in malnutrition and other serious mental, psychological and physical health complications, such as depression, heart disorders, and risk of suicide. In some cases, the patient may need to be fed through intravenous feeding.

6. Anorexia Nervosa: Opportunities in Treatment

6.1 Levels of care

Majority of anorexia nervosa treatment centers provide multiple level of treatment to adequately support patients on the path to recovery. The outpatient or day treatment program is the least intensive level of care, this treatment type is formulated to help patients who are medically and psychiatrically stable, and can benefit from ongoing counseling. Most times, this level of care is endorsed to individuals who have undergone residential treatment as they integrate back into their daily lives.

In addition, majority of anorexia treatment centers render a more comprehensive residential treatment program. This type of treatment program is ideal for adolescents that may be experiencing both medical and psychological issues associated with eating disorder. Eating disorders such as anorexia nervosa requires medical supervision and guidance before or while a patient is working on the psychological aspects of the condition. With residential care, adolescents are able to get the treatment needed for any medical issues associated with the disorder and find comfort in a safe space where their thoughts and feelings can be fully utilized.

7. Engagement

Most people with anorexia nervosa find it difficult to admit that they have a problem and are undecided about change. This is a contributing factor to their reluctance to engage with treatment and services. Effective engagement of the patient in the treatment is a prerequisite for any successful treatment plan, health care workers who are involved in the treatment of anorexia nervosa should ensure to build an empathic, collaborative and supportive relationship with patients and, if possible, their careers. This should be paramount to the care given, motivation to change may go up and down over the course of treatment and the therapist must remain sensitive to this.

8. Comprehensive care offered within a controlled environment

One significant benefit of residential treatment is the comprehensive care which is being offered in a controlled environment, including medical, psychotherapy, and psychiatric supervision and treatment, medical nutrition therapy, support groups, and more. The kind of treatment provided is holistic, this can be advantageous for an individual who is in the early phases of recovery or needing constant supervision and monitoring.

Having the opportunity to establish recovery in a safe and supportive environment can be of added advantage for individual to heal and recover, particularly if their previous home condition or surroundings was not conducive to eating disorder recovery. There might be need for an individual to vacate temporarily from their environment or everyday demands in order to prioritize their healing and focus more on their recovery efforts.

9. Nutrition interventions help to normalize eating habits

Nutrition interventions and meal support can help an individual learn how to stabilize eating habits, restrict poor food behaviors, and learn to eat adequately for their own body needs. Therapy and nutrition interventions are implemented and monitored by specialized team members, which includes a psychotherapist and registered dietitian who specializes in eating disorders.

10. Challenges in Treating Anorexia Nervosa

From the Lancet, “Stephan Zipfel and colleagues present results of the Anorexia Nervosa Treatment of OutPatients (ANTOP) study, in which two manual-based outpatient treatments (focal psychodynamic therapy and enhanced cognitive behaviour therapy) were compared with optimised treatment as usual, which included careful and regular monitoring by family doctors linked to care at specialist treatment centres” [8]. The findings provide some rather sobering observations about treatment of anorexia nervosa, and highlight the difficulties of implementing clinical trials for this disorder. This include treatment for anorexia nervosa takes a long time, at an average of 10 months’ duration. No brief interventions for the disorder have been judged effective. Also, response rate was low as almost a third of patients were lost to follow-up a year after the end of treatment (although, compared with other anorexia trials, this dropout rate is not bad). For many patients, psychotherapy alone did not suffice, and inpatient treatment was needed for some patients during the trial [8].

Challenges with residential treatment are of various dimensions and can include various factors, including intensity of treatment care and cost. If there is no insurance coverage, the cost of residential treatment can be difficult to afford, while some insurance companies will only cover a limited length of stay within residential care.

For some people, transiting from residential treatment to lower levels of treatment can be very difficult, as residents are not always prepared and equipped for the triggers of the outside world after their stay.

There should be allowances made for intermittent hospitalisations during anorexia outpatient trials because recovery from this disorder is rarely linear. Moreover, precipitous weight loss and other medical complications needing hospital treatment do not necessarily mean that outpatient care will ultimately fail.

Establishing a collaborative working relationship with families with a young person with anorexia nervosa presents a particular challenge that requires time and expertise to balance the competing needs of different family members.

A prominent challenge in treating anorexia is that people may not want treatment. Barriers to treatment include:

• Not seeing anorexia as an illness but rather a lifestyle choice

• Thinking you do not need treatment

• Fearing weight gain

People receiving inpatient treatment for anorexia nervosa have been found to be twice as likely to drop out of treatment compared to general psychiatric inpatients [9].

11. Conclusion

Anorexia nervosa is an eating disorder with short and long term physical consequences. Engagement of patient in treatment plan, getting support from family and friends are vital to successful treatment. Most patients with anorexia nervosa receive treatment solely on an outpatient basis. However, a substantial minority receive inpatient treatment. Hospital admission may be at ameliorating the effects of the illness on the patient’s physical or at achieving progress toward full recovery.

12. Recommendations

• Patient and, where appropriate, careers preference, should be put into consideration in deciding which psychological treatment is to be offered.

• Majority of people with anorexia nervosa should be managed on an outpatient basis embedded with psychological treatment, this should be provided by a health care professional competent to give the treatment and also assess the physical risk of people with eating disorders.

• Treatment and physical monitoring for anorexia nervosa should not exceed six months’ duration in psychological outpatient care.

• If outpatient psychological treatment does not lead to any significant improvement, inpatient care should be considered.

• Dietary counseling should be part of the treatment for anorexia nervosa

• Family members including siblings, should normally be included in the treatment of anorexia nervosa.