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A Complicated Process: Diagnosing and Treating Anorexia Nervosa and Bulimia: Page 4 of 11

A Complicated Process: Diagnosing and Treating Anorexia Nervosa and Bulimia: Page 4 of 11

About one-third of patients with BN will have a lifetime history of alcohol or drug abuse (Bushnell et al., 1994). In another study, the relationship between substance abuse in patients with BN was found to be far stronger than in patients with AN (Holderness et al., 1994).

Although many of the studies of personality disorders and eating disorders are contradictory, almost all have shown a high preponderance of Cluster B (impulsive) personality disorders associated with bulimic subtypes compared with the anorectic restrictors (Braun et al., 1994; Herzog et al., 1992). In the 1994 study by Braun et al., borderline personality disorder was present in 26% of the bulimic subgroups and was the most common Cluster B condition. In that study, Cluster C (anxious) personality disorders were present in 26% of the sample and did not vary according to eating disorder subtype. Steiger et al. (1994) found that personality disorder classification did not predict the severity of bulimic symptoms or the responsiveness to treatment of bulimic symptoms.

It is necessary to diagnose comorbid psychiatric disorders since they may complicate treatment strategies.

Treatment Options

The intensity of treatment for the patient with an eating disorder will depend upon the severity of illness. The latter is determined by the patient's weight, medical status and other psychiatric comorbid problems. Seriously ill patients will require a specialized eating disorder inpatient unit where intensive medical management and/or monitoring for suicidal and impulsive behaviors can be conducted. Medical management requires weight restoration; nutritional rehabilitation; rehydration and correction of serum electrolytes; and daily monitoring of weight, food and calorie intake, as well as urine output. Patients must be closely monitored for vomiting and drug abuse behavior.

Less severe patients can be treated in a partial-hospitalization or day program, and those who are not in medical danger and are functioning fairly well can be treated in outpatient care. Table 3 and Table 4 contain guidelines for levels of care for patients with eating disorders.

Anorexia nervosa. For AN, a multifaceted treatment approach is the most effective and includes medical management, psychoeducation and individual therapy utilizing both cognitive and behavior therapy principles. Controlled studies have shown that children under age 18 do better if they also have family therapy (Russell et al., 1987). Nutritional counseling and pharmacological intervention can be useful components to the treatment plan.

There are fewer than 10 randomized, controlled treatment studies in AN. This is most likely because these patients are resistant to treatment and are prone to develop serious medical complications that require withdrawal from research treatment protocols. Cognitive-behavioral therapy (CBT) can be used in both inpatient and outpatient settings. Cognitive-behavioral therapy for patients with AN was carefully developed by Garner and Bemis (1982) and later expanded into a manual for a collaborative multicenter study. This type of treatment must be conducted by well-trained, experienced therapists. Monitoring is an essential component of CBT. Patients are taught to monitor their food intake, their feelings and emotions, their bingeing and purging behaviors, and their problems in interpersonal relationships. Cognitive restructuring is a method in which patients are taught to identify autonomic thoughts and challenge core beliefs. Problem solving, which is also part of CBT, is a specific method whereby patients learn how to think through and devise strategies to cope with their food-related and/or interpersonal problems.

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