The mainstay of outpatient treatment for adults with AN and BN is psychotherapy, the goal of which is the interruption of problem behaviors and normalization of eating behavior. To recover, the patient must undergo a conversion from seeing dieting behavior as a solution to viewing it as the primary problem. Only after behavioral change is accomplished should treatment move on to address predisposing factors, such as family conflict, personality vulnerabilities, and a chaotic personal life. Although individuals may wish to engage in intellectual pursuit of the "causes" of their disorder rather than changing their behavior, such an approach is fruitless and similar to the alcoholic engaging in exploration of the reasons why he or she drinks while continuing to consume alcohol. Once the behaviors are extinguished, the rest of recovery can proceed.
Effective treatment depends on setting clear behavioral guidelines (eg, binging and vomiting decrement of 50% over 3 to 4 weeks, weight gain of 1 to 2 lbs/week on a prescribed diet). The patient should be weighed at the beginning of each session and be instructed to maintain a daily food log and record of abnormal behaviors, such as vomiting or use of laxatives. Triggers for eating disordered behavior and situations that sustain it are discussed and alternate thoughts and behaviors are explored. The therapeutic approach is cognitive-behavioral and fairly directive, with the therapist playing an active role in helping the patient problem solve, develop healthier behaviors, and challenge irrational beliefs. Although the standard course of cognitive behavioral treatment for uncomplicated BN is brief, on the order of 16 to 20 weeks, persuading patients with AN to gain weight as outpatients is difficult, and outpatient psychotherapy for AN may be more protracted.
In addition to individual therapy, group therapy is a powerful treatment modality for behavioral disorders of all kinds. Myths associated with eating disorders are more effectively dispelled in a group. Confrontation about maladaptive behaviors (eg, lying about caloric intake, concealing vomiting, blaming others for one's own difficulties coping with the illness) often falls on deaf ears when coming from a clinician, but is powerful when coming from a peer who has engaged in the same behaviors.
Family therapy has been demonstrated to be highly effective in the treatment of adolescent eating disorders, particularly AN (Russell et al, 1987; Eisler et al, 1997). The explicit treatment aim is to assist parents in regaining appropriate parental control over their child's eating behavior and weight gain.
Failure to achieve behavioral goals despite weekly follow-up meetings and a 1 to 2 month trial of outpatient care indicates a need for inpatient or partial hospital treatment on a dedicated eating disorders specialty unit.
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