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TABLE 26-2. Treatment approach to anorexia nervosa

Table 26-2. Treatment approach to anorexia nervosa.
1. Assess and treat the medical complications of starvation. Determine whether purging is present, and treat for dehydration and electrolyte imbalance as necessary.
2. Decide whether hospitalization is necessary. If dizziness, light-headedness, or fainting from bradycardia or hypotension is reported, if any sign of congestive heart failure is present (including reports of dyspnea on exertion), if fluid and electrolyte balance cannot be maintained, if excessive exercise presents a risk of congestive heart failure and cannot be monitored safely as an outpatient, if cognitive impairment from starvation precludes the utility of outpatient psychotherapy, or if the patient reports mental exhaustion from battling food and eating issues, then hospitalization is essential. Hospitalization is also indicated when reasonable outpatient efforts have failed.
3. Complete laboratory investigation. This includes full electrolyte profile including potassium, magnesium, calcium and phosphates, glucose, complete blood count, erythrocyte sedimentation rate, total protein, albumin, liver function tests, renal function tests, thyroid function tests, iron, folate, B12, electrocardiogram, chest x-ray, and bone density studies.
4. Restore nutritional balance through normal eating and encourage weight gain. This often involves setting up a behavior modification protocol. Low-dose neuroleptics or benzodiazepine-class anxiolytics may be used if fear of weight gain is excessive. Cyproheptadine may be useful to encourage weight gain in cases where weight loss is extreme.
5. Diagnose and treat psychiatric comorbidity. The presence of affective disorder may warrant the use of antidepressant medications. These medications may not be particularly effective when patients are significantly underweight but may be very effective when weight gain has occurred. Issues stemming from personality disorders should be addressed in psychotherapy.
6. Identify and treat underlying ideas, attitudes, and psychological conflicts. Treat with cognitive and/or psychodynamically based psychotherapy.
7. Assess the family. Utilize family therapy to facilitate support for the patient and to address family dynamics that may be contributing to the patient's development of illness.
8. Provide ongoing support. Support healthy diet and exercise habits; constructive approaches to self, family, and interpersonal problems; enhanced self-esteem; and sense of autonomy with ongoing psychotherapy.