The first decision to be made is whether the patient requires resuscitation, rehydration and/or replacement therapy.
Definitive treatment consists of
Outpatient treatment can be tried if the patient is not extremely unwell due to either physical or psychiatric complications.
There is some evidence that family based therapy is effective in the outpatient management of eating disorders in young people. This is a specific style of psychotherapy requiring specifically trained therapists. If weight loss continues, or medical or psychiatric complications or family crisis supervene, or compliance remains poor and no weight is gained, hospitalisation is needed. Ideally this will be in a specialised multimodal program with access to medical and psychiatric expertise and services.
As well as a refeeding program, psychotherapy consists of work with a psychiatrist, specialist nurse, family therapist and psychologist in individual and group settings. The aim is to ensure nutritional recovery and then incorporate an understanding of the personal significance of
Patients and their families require assistance to complete the adolescent tasks of separation and identity formation.
Particular management may be necessary for the patient who has suffered physical, emotional and/or sexual abuse. In some cases where there is significant acute medical compromise due to very low weight, rapid weight loss or chronicity of illness, hospitalisation is required to reverse medical instability.
This is manifest primarily by any or all of:
Management of this requires a careful approach to nutrition and fluid management in order to avoid refeeding syndrome in the acute phase. An approach to the initial management and avoidance of refeeding syndrome is outlined in the following resource:
Anorexia nervosa is a chronic illness with duration of around 5 years on average, although there may be differences for those will earlier onset of illness. Historically the relapse rate has been high (50% in the first year and 90% overall), the death rate is 1% per year with 20% dead by 20 years. Treatment must thus continue for a long period of time even after weight and eating patterns have normalised.
The patient may resist having treatment at all and be determined not to gain weight, in which case compulsory treatment may be necessary. Some patients require medication, most commonly antidepressants, either for depressive illness or for obsessive compulsive symptoms which may impede recovery.
Refeeding syndrome: risk assessment and management, pages 47-49 from the Eating Disorders Toolkit, which has been provided as a comprehensive document on the website for the Centre for Eating and Dieting Disorders www.cedd.org.au
Eating disorders – overview and managementsmp.sydney.edu.au/compass/teachingactivity/view/id/3744
Alice’s new friend (Flexible, self-directed PBL)smp.sydney.edu.au/apps/cds/x/12558.html
Kohn MR, Madden S, Clarke SD. Refeeding in anorexia nervosa: increased safety and efficiency through understanding the pathophysiology of protein calorie malnutrition. Curr Opin Pediatr. 2011 Aug;23(4):390-4.
opac.library.usyd.edu.au/record=b4108361~S4
Herpertz-Dahlmann B. Adolescent eating disorders: definitions, symptomatology, epidemiology and comorbidity. Child & Adolescent Psychiatric Clinics of North America 2009; 18 (1) 31-47
opac.library.usyd.edu.au/record=b3776521~S4
Herpertz-Dahlman B, Salbach-Andrae H. Overview of treatment modalities in adolescent anorexia nervosa. Child & Adolescent Psychiatric Clinics of North America 2009; 18 (1) 131-45
opac.library.usyd.edu.au/record=b3776523~S4
Steinhausen HC. Outcome of Eating Disorders. Child & Adolescent Psychiatric Clinics of North America 2009; 18 (1) 225-42