Behavior therapy consists mainly of positive reinforcements for weight gain. The outpatient needs to be weighed weekly and the inpatient daily. Response prevention techniques are used to stop bingeing and purging. For example, in the inpatient setting, the patients may be required to sit together in a living room for one hour after eating. An in-depth discussion of CBT for AN can be found in Kleifield et al. (1996). Two studies comparing CBT with nutritional counseling have shown the former to be significantly superior in treating AN (Pike et al., 2003; Serfaty et al., 1999).
British studies have shown that adolescents who receive family counseling for treatment of AN do significantly better than those who do not (Dare and Eisler, 2001; LeGrange et al., 1992; Russell et al., 1987). These studies demonstrated that brief therapy separately involving parents and their daughters can be as effective as conjoint family therapy in which the whole family is treated together. In both forms of family therapy, the responsibility is placed on the family for changing eating behavior and weight gain in the patient.
Medications should be considered as an adjunct treatment for AN. Cyproheptadine (Periactin), a serotonin antagonist and antihistamine drug, has been shown to facilitate weight gain and reduce depressive symptomatology in patients with AN in a double-blind, placebo-controlled trial (Halmi et al., 1986). Cyproheptadine has the advantage of not having the tricyclic antidepressant side effects of reducing blood pressure and increasing heart rate. This makes it especially attractive to use in emaciated anorectic patients. It can be used in high doses such as 24 mg/day to 28 mg/day with safety.
There is some evidence that fluoxetine (Prozac) is useful in preventing weight relapse in AN and may specifically target the obsessive-compulsive behaviors that are seen with food and weight control (Kaye et al., 1991). There is no evidence that fluoxetine is effective in treating low-weight anorectics. Although chlorpromazine (Thorazine) was the first drug used to treat patients with AN, there are no double-blind, controlled studies to definitely prove its effectiveness for reducing core anorectic symptomatology and for inducing weight gain. Clinical experience has shown this medication to be particularly helpful in the severely ill patient who is overwhelmed with constant thoughts of losing weight and has uncontrollable behavioral rituals. It is better to start chlorpromazine at low doses of 10 mg tid and increase the dose gradually, monitoring blood pressure and side effects.
More recently, olanzapine (Zyprexa) has been demonstrated in several cases to be effective in inducing weight gain and reducing anxiety in patients with AN (Boachie et al., 2003; Malina et al., 2003; Powers et al., 2002). Controlled and open studies with this olanzapine are currently being conducted. Again, it is wise to start the medication at a low dose of 2.5 mg/day and gradually increase the dosage, monitoring side effects. Many patients are aware of the weight gain side effect of olanzapine and thus refuse to take this drug.
Unfortunately insurance coverage for psychiatric inpatient treatment for AN is almost nonexistent in many areas of the United States. This limits care to brief medical hospitalization and outpatient care. The impact of these policies on the long-term outcome of AN needs to be studied.
Bulimia nervosa. Cognitive-behavioral therapy is a most effective treatment, proven in 35 controlled studies of BN. About 40% to 50% of patients are abstinent from both bingeing and purging at the end of treatment (16 weeks to 20 weeks). Improvement by reducing bingeing and purging occurred in a range from 70% to 95% of patients. Another 30% who did not show improvement immediately posttreatment showed improvement to full recovery one year after treatment (Walsh et al., 1997; Wilson and Fairburn, 2002). In patients with BN, CBT interrupts the self-maintaining cycle of bingeing and purging and alters the individual's dysfunctional cognitions and beliefs about food, weight, body image and overall self-concept.
Three studies have combined CBT with antidepressant medication: One of those showed no additional benefit, and the other two showed the combination was superior to CBT or medication alone (Wilson and Fairburn, 2002).