Anorexia nervosa (AN) is a severe and debilitating illness with one of the highest mortality rates of any psychiatric disorder. Epidemiologic studies show that AN affects males and females, children and adults, and individuals of all races and ethnicities, although some data suggest that it is most prevalent among white females.1 AN is characterized by severe food restriction leading to an unhealthily low body weight, as well as body image distortion and intense fear of weight gain.
The illness course is often long, recovery is slow, and the rates of full recovery are low. Currently, treatments that emphasize behavioral change (with monitoring of eating and weight) are the most useful, with no one modality emerging as the treatment of choice. Medications have been generally disappointing, and none to date have been approved by the FDA for treatment of AN. A recent, large randomized controlled trial suggests a potential benefit of olanzapine for outpatients with AN.2
Eating behavior in AN is, in many ways, impressively stereotyped. When food intake has been carefully measured through observation or laboratory studies, individuals with AN have been shown to limit caloric intake, and to specifically limit intake from fat. Dietary restriction occurs during acute illness and does not normalize with weight restoration.3 Food restriction can begin for a wide range of reasons beyond intent to lose weight. Some individuals, for example may experience weight loss due to a medical illness, or after joining a new sports team.
Once restrictive eating behaviors are established, they become remarkably similar across individuals with AN: low-calorie diets with limited food variety and in particular, avoidance of fat. Eating is also associated with high anxiety and often accompanied by ritualized behaviors. Eating behavior studies underscore that the salient and central problem of AN is maladaptive eating.
Specialized behavioral inpatient units are highly successful in helping individuals with AN get renourished.4 Unfortunately, relapse rates post-hospitalization are high. One challenge in treating AN is that maladaptive eating patterns persist even after acute treatment and have been shown to predict worse outcomes in the longer term.5 Individuals who were eating a wider variety of foods, and consuming food with higher energy density toward the end of their inpatient stay were more likely to be doing well one year after hospital discharge. Understanding how these patterns form and why they persist can provide insights into how to better treat this disorder.
Ms Rufin is a graduate student in public health, and Dr Steinglass is Associate Professor of Clinical Psychiatry, Department of Psychiatry, Columbia University Irving Medical Center/New York State Psychiatric Institute, New York, NY. Ms Rufin reports no conflicts of interest; Dr Steinglass reports that she has financial interests in UpToDate, the Klarman Family Foundation, the Hilda and Preston Davis Foundation, the National Eating Disorders Association, and the NIMH.
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