The latest thinking on Anorexia Nervosa Treatment, for sufferers & the people who love them
Anorexia Nervosa a brief outline
I am writing this article for people who want a quick overview of anorexia treatment in a way that is easy to read. Anorexia is a condition which we call a relentless pursuit of weight loss and a refusal to maintain a normal weight. This refusal is driven by intense fear. The symptoms of anorexia include starving, avoiding any foods that might result in weight gain, running, the need to eat clean food, or to avoid animal products. Some people engage in excessive exercise and may have strange eating rituals.
Symptoms of anorexia also include apparent cheerfulness even at low weights, while the person is actually lonely and depressed. Sufferers have poor body image and very low self-worth. They may be convinced that they are fat even when they are very thin. They withdraw from normal social interactions and may deny that anything is wrong, becoming secretive and angry if their behaviour is challenged.
In early stages of anorexia, they believe that low weight is a good thing, for them, if not for other people, and when the illness is entrenched, they feel successful and may become infatuated with their thin appearance in the mirror.
Anorexia is not a lifestyle choice and it is not a slimming disease. It is a serious, lethal, mental health disorder. It lasts for about 7 years but people can recover much sooner, much later or not at all. Anorexia is lethal if it becomes long-term, death from suicide is not uncommon, because chronic low weight leads to severe depression. If we catch anorexia early, we have the best chance of full recovery.
Why Do People Develop Anorexia?
People who develop anorexia have high risk of getting any mental health problem at a time in life when it is hard to cope and to keep up. The most common risk factor is high sensitivity and there is some evidence of anorexia genes. There is usually a history of unbearable stress.
People feel out of sorts s and look for a way to feel better. For people who develop anorexia, the way to feel better is to lose weight, then they cannot stop. They start hearing a Voice which tells them to keep going, for reasons we don’t fully understand. They keep going because they CAN; They seem to have a way of mastering their normal hunger drives, they like the clear simple rules of the anorexic way of life and they do feel better for a while.
In time they discover, unconsciously, that anorexia is useful. They feel special and wear their thinness as a badge of pride. Their emotions are dulled by starvation and they enjoy not being bothered by troublesome feelings which may have been hard to manage before the illness set in. Warring families might unite to help their loved ones. The person gets attention, even though they do not want it; it is as if part of them is saying, I am in pain but I’m not sure why. This weight loss is showing you all that I am unhappy. This illness is to stop me from being present in my own life.
People who develop anorexia have been very unhappy and commonly very anxious, before they decided to lose weight. There are many reasons for this unhappiness. Perfectionism and anxiety are part of this stress. They may lack other emotional skills that are needed to cope with life better. Only a very thorough assessment will show us what is “missing”. Treatment of anorexia must focus on helping the anorexic person feel strong and capable, not just “regain weight”.
Anorexia Treatment Challenges
The goal of anorexia treatment is to help someone feel able to take care of themselves nutritionally and to accept a healthy weight. They will be able to eat with others without fear and avoidance and have a flexible diet. But that is not all. We want to build something that is bigger than the eating disorder and achieve everything else that is important to them. We hope to deal with the missing pieces and make them emotionally resilient; to like themselves better and not need starving as the only means they have to feel good about themselves.
The symptoms of anorexia can always be managed by taking control of their eating away from them, by getting them to eat more. But this does not mean that they are cured and often leads to resistance and relapse.
Our problem is; re-feeding is necessary to keep someone safe and avoid the many physical and emotional side effects of low weight. Low weight is deadly and causes depression, OCD and despair. Psychological interventions need brain food in order to work. So we are stuck between a rock and a hard place. People with anorexia do not want to eat. They mean to lose weight and they have succeeded. Why give it up; it took a lot of hard work to get where they are. It is useful to them.
Yet we cannot repair the psychological deficits of anorexia if someone is not eating a wide diet delivering all the necessary calories and nutrients. Their brain will not work.
Poor Motivation for Treatment in Anorexia
One of the first important parts of anorexia treatment is to explore all the ways in which low weight is useful to them. We can bring this all to the surface, reduce stigma and create a wee bit of a conflict about wanting to change. We need to ask what “change” means to them and help them discover how anorexia might interfere with their dreams. We do not tell people that they will feel better if they eat more. They will not feel better. That kind of conversation is unhelpful.
Some people will argue that they do not even have anorexia. We can accept this and ask them to give another name to their symptoms. There is no need to insist on a diagnosis, because this does not make it easier to treat them. There is no weight that defines anorexia. People with anorexia ARE hungry. Anorexia is simply intense fear of eating, wishing to be a bit thinner whatever weight you are. It is hearing a Voice which punishes you if you break your eating rules.
Anorexia Nervosa Treatment Goals
Anorexia treatment is two-sided. We must help bring the weight loss impulses under control and restore weight. This supports the psychological side of treatment. Psycholgical treatment helps a person to feel in control, manage their emotions well, deal with unhelpful anorexic thoughts and rebuild self-worth. The psychological treatment will help the person feel that they deserve to eat and make friends again with food. Their emotional survival will no longer be connected with starvation.
This can take a long time. There is no quick-fix for treatment of anorexia nervosa. We may need to involve loved ones, carers, workplace or school support. We may to build a scaffold of support around a person with anorexia so that they can stop being a servant to the rules of anorexia.
Anorexia Treatments Overview
There is more than one treatment approach for anorexia. But all treatments target the factors that maintain the illness including the effects of low weight.
Re-feeding approaches must always be guided by a dietitian – not a nutritionist. A dietitian is trained to identify the exact calorie and nutritional needs of anorexia and to correct any damage that starvation has caused. Starvation and muscle loss change the metabolic needs of patients and there may be dangers associated with the wrong kind of re-nutrition. A doctor, working alongside a dietitian will be able to manage symptoms such as slowed digestion (gastroparesis), pain on eating and dangerous hormone shifts.
There are many therapies for anorexia. The question is how to find the right one for each particular person. Any one of these therapies might work and if one doesn’t work, the best thing is to try something else instead.
Assessment for Anorexia
Assessment must be very thorough, to identify how serious the condition is now, and what must be done right away. Some people, not all, might be in physical danger and may need emergency help for low blood sugar or organ failure, Thankfully such cases are not common.
The eating disorder specialist will get to know about the history of the anorexia and when it really began in terms of creeping worries about weight and food. We must find out whether something else is going on such as self- harm, extreme thoughts of despair, OCD, trauma, abuse, social phobia or an anxiety disorder.
More importantly, we will get to know the person – their hobbies and interests, their goals and dreams. We will help the person find out if, and how the anorexia will get in the way of the other things that matter in their life. Someone with anorexia must never be threatened or told-off for their behaviour. Their behaviour is, at this point in time a survival strategy. They need to know we care.
Motivational Therapy for Anorexia
Motivational therapy is a first-choice intervention for anorexia. It recognises that anorexia is useful and desired, it is often so entrenched that is has become an identity. People prefer the “con/ costs” of anorexia to the possibility of a life without it. And some people describe their anorexia as a friend or a guardian angel. Motivational therapy helps a person to express everything that is good about the condition; sometimes he or she is not consciously aware why they fear change. A properly trained therapist will assure people that recovery is about thriving, being happy; not just gaining weight.
Family Behaviour Therapy for Anorexia
Family Behaviour Therapy is for younger patients; the family and therapist help the person to eat regularly. A prescriptive diet will help their physical health, restore bone growth and relieve the intense depression that accompanies starving.
The parents or carers are taught to supervise all meals and to deal with conflicts at home, with the support of the therapist. The eating plan must be designed by a dietitian to accommodate age and health-related needs. This therapy benefits from support outside the home from carer groups or therapy for carers. It is not an easy therapy to apply because few people like to eat more than is comfortable. However, it does have a high rate of success for people who complete the treatment.
Enhanced CBT for Anorexia
CBT (adapted for eating disorders) has a good press for the treatment of eating disorders, but works less well with low weight patients. This enhanced form of CBT has a good outcome. The focus of this therapy is to modify the over-importance of body shape and weight and its influence on self-esteem which drives the behaviour of all the eating disorders. When body image becomes less important, symptoms are relieved and the patient is able to life a fuller life. This therapy also targets some of the emotional frailties of anorexia nervosa. Patients with anorexia do not manage their emotions well, bad emotions make them feel like bad people and thus emotions must be blocked. CBT-E is a form of treatment delivered in a manual form and can be done online. Only a therapist who is fully trained in the principles of CBT-E (not just CBT) can deliver this therapy.
Family Therapy for Anorexia
Anorexia is like a possession (not literally) and can be maintained by unhelpful communications from carers, such as imploring the patient to eat or telling a person how much you are hurting (which is probably true). Family Therapy teaches carers how to BE with a patient in order to help them to help themselves with the anorexia. The family will learn the animal models of communication (you can check this online) and how to speak to the person who is struggling rather argue with the “possession” which appears to have captured them. Carers need to avail themselves of these skills and can attend carers workshop, or read as much as they can about how to help, online.
A Mantra Programme for Anorexia
This is a treatment for anorexia which is delivered at the Maudsley. Elements of this programme can be done by a properly trained eating disorder therapist in private practice. This therapy addresses under-eating with the help of a dietitian and alongside this we address the underlying functional deficits we see in anorexia. These deficits include rigidity & inflexibility, over-focus on details (but not being able to see things from other points of view including the “big picture”); perfectionism, and fear of uncertainty / ambiguity.
Fear of uncertainty and ambiguity is a common feature of anorexia which makes life feel very testing. You are able to see from this list of deficits why people with anorexia find it hard to cope and why they find it hard to deal with relationships which are invariably challenging as we go through life.
I have explained in this paragraph WHAT to do. But HOW to do all this is the task of an eating disorder therapist who is trained in a therapy called Cognitive Remediation. Part of this therapy includes picture work as well as the usual strategies of helping people to become more flexible, less hard on themselves and more effective.
Expressive-Emotional Therapies for Anorexia
Anorexia arises in people who find it hard to deal with emotions, to know what they feel, to experience negative emotions without shame and to deal with their emotions without panic and alarm. The emotional blanking of anorexia is one of the things that make anorexia useful. Weight regain often brings powerful feelings back into life, so we need to work with emotions.
Expressive therapies such as painting, drama and modelling help people to access emotions safely. We also need to teach self-soothing skills that were formerly lacking. A wide range of therapies is available, including DBT (Dialectical Behaviour Therapy) Tapping, Trauma-based therapy like EMDR or ReWind for people who have had adverse experiences in early life. People with a history of anorexia may always be sensitive, but they are able to deal with it better. The goal of therapy is to build emotional resilience and there are many ways to achieve this.
Focal Psychotherapy for Anorexia
If cognitive styles of therapy do not work, this might be helpful. Focal psychotherapy looks at all the early experiences which might have contributed to the choice of food restriction as a way to cope. At the NCFED, part of our assessment process includes looking in detail at early life experiences. In this way we can build a picture of the patient as a person, not just their illness. Careful use of this psychotherapy will help to boost self-worth. Psychotherapy alone is not an alternative to real-time help with eating and nutritional rehabilitation.
Schema focused CBT is a form of focused psychotherapy for anorexia. People with anorexia nurse underlying harmful “schemas” or belief systems; – core feelings of badness, being contaminated and being ineffective. The outcome of these feelings is perfectionist behaviour, avoiding unclean or immoral foods, (orthorexia) and abusing themselves with dangerous behaviours. SF-CBT must be delivered by a trained psychotherapist and it is useful to help people feel better about themselves.
Cognitive Therapy for Anorexia
Anorexia is maintained by a host of unhelpful beliefs about food, shape and weight such as “All fat is bad” or “if I eat something forbidden, I will gain a huge amount of weight”. Anorexic attitudes include thinking in rules and in extremes – which we call black and white thinking; beliefs like “I’ve done this so long what is the point of giving up now”. Anorexics also have very concrete beliefs such as “If I think I am fat, I AM fat”. This mindset generates powerful feelings and beliefs like this largely delusional, so there is little point in trying to argue a different point of view. We could arguably say that these beliefs are partly the influence of a malignant Anorexic Voice.
Cognitive approaches will help to defuse these beliefs and reduce the hot emotions that they cause. We can help people to think differently by naming these beliefs as “Eating Disorder thinking” or help people to deal with these beliefs with a therapy called Cognitive Defusion, which has its roots in Zen Buddhism. Targeted Cognitive therapy is nicely illustrated in Jenni Schaefer’s book: Life without ED.
Media Literacy Treatment
This is not so much a therapy, as a treatment approach to be built into therapy. People with anorexia often seek thin-spiration to inspire and motivate their weight-loss efforts. They need to be educated about the tricks of the trade which are used to sell thin images on all kinds of media.
At times, this need for inspiration or support leads patients onto pro-anorexia websites. Inside these eating disorder forums, they meet like-minded people who educate them into harmful behaviours to control their hunger or inspire more weight loss. Because people with anorexia feel lonely and isolated, fear of rejection and isolation may keep them trapped with people who will manipulate them into more self-harm. Secrecy is the usual hallmark of membership of pro-anorexia online.
There is no easy solution to the addiction of harmful social media. We try to see if it is going on and then if it is, work over a period of time with someone and try to direct them to recovery sites instead. Leaving pro-anorexia content is experienced as a loss; this is something that we have to accept and manage with care. And with compassion.
How To Support Recovery from Anorexia
Recovery from anorexia brings its own challenges which can derail progress. As weight rises, the recovering person can feel emotional and all at sea. They may feel very fat, and still feel lonely, disconnected and vulnerable. Their weight may be up but they may not have fully learned all they need to cope with life and other people.
Because people think that they are OK now, they may be left alone, expected to just carry on as usual. In our experience, a therapist needs to continue seeing a patient but tread a fine line between making them dependent on therapy and helping them to become autonomous. A recovered person has robust self-worth and is capable of self-care. We must help our patients to recognise well in advance any signs that the anorexia wishes to return, such as deciding to run a marathon “to raise money for charity”.
Carers need to be very alert to how their loved one is coping with a life change, such as leaving home for the first time, or having a child. Anorexia can be cured, and at the same time is always a whisper away.
How to Personalise Anorexia Treatment
There is no formula for treating anorexia which will work for everyone.
The first thing is to do a specialised, in depth assessment which will identify the current medical risks and the seriousness of the illness, we can decide WHO the patient is and if they need emergency help such as being in hospital or not in school.
We urge all readers to get young people to a doctor if they suspect the signs of anorexia. A young person needs to be in CAMHS. Read up on the warning signs. Changing diets, becoming vegetarian, getting upset about fat on foods, withdrawing from normal company, increasing exercise, asking if they are fat. There is not a single sign of anorexia. If you are worried, take action fast. Speak to the school, ask other family members, speak to a friend. Speak to the patient and say without emotion what you have observed.
At the NCFED, we suggest that only a specialised therapy will help with anorexia. This kind of therapy demands a team, where the person, a doctor, a dietitian and carers work together and expect that there will be steps forward and back. We are sorry to say that anorexic treatment is not a quick fix. Getting treatment early helps. If the person denies that there is a problem, do watchful waiting and tell the person gently that this is what you plan to do.
If you need help with getting a treatment plan in place for your loved one or for yourself, consider speaking to us. We have people who can help and who are trained to help. Help is just one phone call away.