The condition runs a fluctuating course, with exacerbations and partial remissions. Long-term follow-up suggests that about two-thirds of patients maintain normal weight and that the remaining one-third are split between those who are moderately underweight and those who are seriously underweight. Indicators of a poor outcome include:
• A long initial illness
• Severe weight loss
• Bulimia, vomiting or purging
• Difficulties in relationships
Suicide has been reported in 2-5% of patients with chronic anorexia nervosa. More than one-third have
recurrent affective illness, and various family, genetic and endocrine studies have found associations between eating disorders and depression.
Treatment can be conducted on an outpatient basis, but if the weight loss is severe it is accompanied by marked physical symptoms of lassitude, dizziness and weakness and/or electrolyte and vitamin disturbances; hospital admission may then be unavoidable. Rarely, the patient’s weight loss may be so severe as to be life-threatening. If the patient cannot be persuaded to enter hospital, compulsory admission may have to be used.
Treatment goals include:
• Establishing a good relationship with the patient
• Restoring the weight to a level between the ideal body weight and the patient’s idea of what her weight
• The provision of a balanced diet of at least 3000 calories in three to four meals per day
• The elimination of purgative and/or laxative use and vomiting
Treatment can be conducted on behavioural or dynamic psychotherapeutic lines or on a combination of both. The usual behavioural approach is to remove privileges on the patient’s admission and to restore them gradually as rewards for weight gain. Intense psychoanalyticallyderived psychotherapy is not helpful. Family therapy, involving the exploration of problems in family relationships and their modification through counselling, is used; however, evidence that it is superior to simple supportive
psychotherapy is lacking.
This refers to episodes of uncontrolled excessive eating, which are also termed binges. There is a preoccupation with food and a habitual adoption of certain behaviours that can be understood as the patient’s attempts to avoid the fattening effects of periodic binges.
These behaviours include:
• Self-induced vomiting
• Laxative abuse
• Misuse of drugs-diuretics, thyroid extract or anorectics
Additional clinical features include:
1 Physical complications of vomiting:
2 Associated psychiatric disorders:
(a) Depression in reaction to vomiting
(b) Alcohol dependence
3 Fluctuations in body weight
4 Menstrual function-periods irregular but amenorrhoea rare
5 Personality-neurotic traits present premorbidly
The prevalence of bulimia in community studies is high; it affects between 5 and 30% of girls attending high schools, colleges or universities in the USA. Bulimia is often associated with anorexia nervosa. The prognosis is uncertain.
It is not yet clear what is the most effective form of treatment. Admission to hospital with careful control over eating has been advocated, while a behavioural approach involving careful diary-keeping regarding eating and making patients responsible for control is under extensive study. In this approach, patients attempt to identify and avoid any environmental stimuli or emotional changes that regularly precede the desire to binge. Results of this approach are promising.