Evidence-Based Reviews

Update on eating disorders Anorexia nervosa: Dual therapy can bring patients back from the brink

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Ms. J started losing weight deliberately at age 14 while attending boarding school. She lost 25 lbs by jogging 6 miles per day, exercising another 2 hours, avoiding meat, abusing laxatives, and drinking large quantities of coffee.

She was referred to a school counselor because of her weight loss and returned home. She was happier at a local high school and recovered to normal weight. In college, however, she reverted to compulsive exercising and preoccupation with her weight after the break-up of her first intimate relationship.

Now at age 22, Ms. J has persistently failed to gain weight during outpatient therapy for anorexia nervosa. At 5′7″ she weighs 98 lbs. On the day she was to be hospitalized involuntarily, she took 25 diphenhydramine tablets, which her psychiatrist viewed as a suicide threat. The overdose was treated in the emergency room with ipecac syrup, and she was admitted for inpatient eating disorder treatment.

Like Ms. J, patients with anorexia nervosa resist treatment and deny having most diagnostic signs and symptoms. Based on the evidence and my 30 years of treating anorectic patients,1 this article offers suggestions to help you:

  • gather accurate histories from patients and their families
  • identify common psychiatric comorbidities
  • gain the patient’s trust during treatment
  • provide effective dual therapy, with cognitive-behavioral and pharmacologic components.

Table 1

Diagnostic criteria for anorexia nervosa

Underweight (<85% of normal for age and height)
Fear of gaining weight or becoming fat, even though underweight
Disturbed conceptualization of body shape and weight, denial of seriousness of low body weight, or overemphasis on body shape and weight in self-evaluation
Amenorrhea. Subtypes:
  • Restricting type (does not binge or purge)
  • Binge-eating/purging type
Source: Adapted with permission from Diagnostic and statistical manual of mental disorders (4th ed. text revision).
Copyright 2000 American Psychiatric Association.

Making the diagnosis

Anorexia nervosa is characterized by underweight, fear of gaining weight, disturbed body concept, and amenorrhea (Table 1). Its core psychological symptoms have been described as:

  • relentless pursuit of thinness
  • denial of cachexia
  • and feelings of general ineffectiveness.2

The patient may say she feels fat even though emaciated or that parts of her body are too large. This disturbed experience of body weight or shape may represent sublimation and displacement for feelings of inadequacy. Because anorectic patients stay thin so effectively, they may feel a sense of accomplishment by evaluating themselves in terms of their thinness. Cognitive therapy focuses on correcting patients’ pervasive sense of inadequacy, as manifest in maturity fears and lack of confidence in coping with life’s problems.3

Subtypes. Anorexia nervosa has two subtypes—restricting and binge eating/purging—that differ in behavioral and medical symptoms.4 Patients with binge eating/purging show:

  • higher rates of impulsivity (suicide attempts, self-mutilation, stealing, and alcohol and other substance abuse)
  • more-prevalent impulsive personality disorders (borderline personality disorder, hysterical personality disorder)
  • medical problems caused by purging.

Restricting-type patients are often dependent and submissive, with difficulty separating from parents. These patients may be preoccupied with orderliness, perfectionism, and control.

Recommendation. A structured interview to diagnose anorexia nervosa is summarized in Table 2. Because the patient will likely deny her symptoms, it is usually necessary to also interview family members or close friends.

Psychiatric comorbidity

Case report continued: A ‘perfectionist.’

School for Ms. J required great effort, and she spent many hours studying. Her upper-middle-class parents described her as “a perfectionist.” The family placed considerable emphasis on doing the “correct” thing.

During adolescence, Ms. J developed a major depressive episode that lasted 4 months. She also developed obsessions and compulsions unrelated to her eating disorder. She obsessively ruminated about the correct things to say in social circumstances and devoted 4 hours per day to cleaning and checking compulsions. She felt she had to wash her car every time before going out; if she could not, she would cancel her social plans.

Table 2

Diagnosis of anorexia nervosa: Questions to ask*

Weight history-What was her highest weight and lowest weight (after weight loss)
-At what ages did these weights occur?
-Ask about her present weight before you weigh her
Eating behavior-What does she eat and when from morning awakening to bedtime?
-Does she eat with the family less often than in the past?
-Is she binging?
Purging behavior-Is she inducing vomiting?
-Is she using laxatives, diuretics, ipecac, or enemas?
Preoccupations and rituals concerning food and weight-Does she constantly count calories and express concern about fat content in foods?
-Does she often gaze in the mirror and comment about being fat?
-How often does she weigh herself?
-Does she express fear of being unable to stop eating?
Activity-Is she jogging, bike riding, or doing aerobics?
-How often, and for how long?
-Is she overactive at home, such as pacing?
Menstrual history-At what age did menses begin?
-What was the date of her last period?
-How regular is her cycle?
Psychiatric comorbidity-Does she have symptoms of depression?
-Impulsive behavior (suicide attempts or self-mutilation)?
-Drug or alcohol abuse?
-Anxiety (obsessive-compulsive behaviors, social phobia, generalized anxiety, fearfulness)?
-Personality disorders?
* Because patients with anorexia nervosa often deny their symptoms and conceal their food intake, it is usually necessary to interview family members or close friends as well as the patient.


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