Treatment of anorexia nervosa: insights and obstacles

Anorexia nervosa is a behavioral disorder characterized by ego-syntonic self-starvation, denial of illness and ambivalence towards treatment. Treatment refusal and drop-out rates are high and relapse is common. Treatment is best viewed as comprised of two phases, weight restoration and normalization of eating behavior followed by relapse prevention. Most patients verbalize a desire to change, however they seek treatment on their own terms, ideally with minimal or no weight gain. Successful treatment must therefore convince patients to overcome their drive to diet. Evidence-based data on treatment interventions for anorexia nervosa are scarce and methodological problems afflict the few published, controlled trials. Taken together, clinical expertise and data from correlational and controlled trials suggest that chronicity and adult status are associated with a worse prognosis. Outpatient family therapy is effective in weight-restoring the majority of adolescent patients whereas older patients, or those with severe medical or psychiatric comorbidity, often require intensive treatment on an inpatient eating disorders behavioral specialty unit. Correlational data suggest that weight-restored patients are less likely to relapse. Despite limitations of the current knowledge-base, several new areas of research hold promise in elucidating risk factors, in identifying the pathophysiology that sustains anorectic behavior, and in developing more targeted and effective treatments.