After medical stabilization, the absolute first priority is to end the starvation, which is a prerequisite for treating the psychological and medical complications of the condition. Because of the patient’s characteristic intense denial and terror of calories, the reversal of starvation is almost invariably met with stiff resistance. It is critical to take a firm stance that continued starvation may be incompatible with survival and therefore cannot be accepted. Initially, the re-feeding process usually entails the use of liquid nutritional supplements. In some cases, particularly when the person is unable (or unwilling) to eat, a nasogastric tube (or the threat of one) is necessary.
The temporary use of a liquid diet has several advantages. Liquid calories often meet with less patient resistance because they sidestep the avoidance rituals associated with solid food. You are also likely to get more calories per swallow and complain less of being bloated. Because liquids are absorbed more rapidly, there is less opportunity for self-induced vomiting. Finally, using a liquid diet allows for a more careful calibration and measurement of total daily calorie intake.
The next steps involve psychoeducation, behavior modification, and cognitive therapy, all directed toward establishing healthier eating habits and body image. A large part of the treatment of Anorexia Nervosa is psycho education — challenging the person’s cherished tenets about food and body weight and providing a healthy undistorted alternative. The treatment of Anorexia Nervosa is quite difficult—it entails having you do the exact thing you have been deathly afraid of—gaining weight.
Therefore, the initial step in treatment is to convince you of the necessity of weight gain and the downsides of your food deprivation. Clarifying the causal connection between your low weight and the symptoms of Anorexia—low energy, difficulty concentrating, mood swings, food obsessions—is often eye-opening and is critical in helping you weather the inevitable struggles ahead.
Behavioral therapy begins with a weight gain contract expecting that a pound or two will be put on each week. Positive and negative behavioral reinforcements are established to help provide motivation—things like TV privileges, going out with friends, or telephone time. A nutritionist can help normalize eating patterns and establish healthy meal plans. A crucial time is the switch from liquid to solid diet.
Phobic desensitization techniques can be helpful if you experience intense anxiety when eating even reasonably caloric foods. You make a list of foods, ordered from least feared (lettuce) to most feared (chocolate cheesecake). With the therapist’s support, each type of food is confronted and conquered. Another behavioral strategy involves figuring out which environmental cues or situations trigger food restriction and excessive exercise. For example, you may be weighing yourself many times a day, and starving because your weight is too high. You should be barred from weighing yourself more than once a week.
Cognitive therapy aims to identify and challenge your distorted thinking about food and body shape. Catastrophization ( Exaggeration ) is common—you are sure that eating a few cookies will result in gaining a pound. You are taught to identify such gross distortions and to counter them with realistic alternatives (it takes more than one hundred low-calorie cookies to equal a pound of fat). Similarly, you must accept that you have lost the ability to objectively assess your weight and body shape. Just as a color-blind person cannot trust his ability to match clothing, you must learn to consider yourself weight-assessment-impaired.
Medication treatment for Anorexia Nervosa has not been particularly successful. Although a wide array of medicines have been tried, none has been shown convincingly to promote weight gain. Antidepressant medication can be effective when significant depressive symptoms accompany Anorexia Nervosa.