**7. Treatment**

Evidence-based research in this area suggests promising results in treatment. At the same time, the treatment processes are reported to be long and especially expensive, almost like schizophrenia, yet full recovery is only possible for half of the patients [82]. A multidimensional treatment with a multidisciplinary team is necessary in AN treatment, as the disorder contains biopsychosocial elements in nature. Medical nutritional therapy for weight gain and nutritional counseling is important, especially in the case of severe weight loss. Pharmacotherapy has a limited role in the treatment and however can be beneficial in some cases. Nevertheless, there is certain evidence that psychotherapy is essential in AN treatment, although a multidisciplinary approach is required that includes nutritional therapy and psychiatric and medical evaluation as well [83]. Inpatient treatment is suggested in cases with a low BMI (<13.5), rapid decrease in weight, risk of suicide, social isolation, failure of outpatient treatment, and medical risk factors (e.g., cardiac problems and lowered blood sugars) [84]. Specialized units and clinics are also required for AN treatment.

## **7.1 Medical nutritional therapy**

Medical nutritional therapy is an essential part of treatment in AN, especially for inpatients. This form of therapy focuses on the evaluation of nutritional problems and risks, and after that nutritional counseling is provided to treat the nutritional disorder and to prepare the patient for the next stages of treatment. In medical nutritional therapy, the first choice is oral feeding (chewing and swallowing), but enteral/tube feeding (giving liquid food to the stomach or intestine) or, as a last resort, parenteral feeding (bypassing the digestive process) is also applicable [5, 83]. Refusals against weight gain are common in these treatments; the nutritional therapist also provides counseling to patients. In severely underweight patients, feeding may cause refeeding syndrome. Although weight gain is the first goal, weight maintenance is the ultimate goal in the long term. Hence, nutritional therapy has a value in the whole treatment process.

### **7.2 Pharmacotherapy**

Research has focused on the impact of several pharmacological agents on anorexia, as neurobiological factors are important in the etiology. Even so, antipsychotics and antidepressants have only a limited role in treatment [85]. However, there is some evidence about olanzapine, an atypical antipsychotic, whose mechanism of action is unclear, which is thought to block serotonin and dopamine, which may be effective in weight gain [86]. In addition, appetite regulators (e.g., dronabinol) and hormone (e.g., estrogen) drugs may contribute to both weight gain and anxiety reduction [87]. In the treatment of AN, antidepressants do not provide

**75**

nance of AN.

*7.3.2 Cognitive behavioral therapy*

*Anorexia Nervosa*

effects [89].

**7.3 Psychotherapy**

dence of success in treatment.

*7.3.1 Family-based approaches*

*DOI: http://dx.doi.org/10.5772/intechopen.91278*

the desired level of benefit, and it is suggested that this may be due to decreased 5-HT1A receptor activity, which is a consequence of starvation [88]. Nevertheless, almost half of the AN cases report using psychotropic medications despite lack of evidence supporting their efficacy, which is also concerning due to their severe side

Psychotherapy is essential in anorexia treatment, and there is a range of psychotherapeutic approaches. The first psychological explanations of AN came from psychodynamic models, although psychodynamic treatments still have only limited effects [66]. Family therapy is the evidence-based psychotherapy type for younger AN patients, and some modifications are offered for adult patients [90]. CBT is the first step of treatment in BN and BED, and it also works for AN to some degree [91]. Other approaches include third wave behavioral therapies and eye movement desensitization and reprocessing (EMDR) therapy, which also show limited evi-

Family dynamics are an important factor in the etiology of AN. The first studies in this area suggested family characteristics such as overinvolvement or inability to solve conflicts; however, family-based approaches put families as part of the solution, not the source of the problem. These approaches originated from the Maudsley Hospital in London and focused on the family system as a whole. Several randomized control trials proved the efficacy of family-based treatments in adolescents with AN [92]. At a basic level, this kind of therapy analyzes predisposing and maintaining family dynamics of anorexia and then plans the treatment procedure accordingly. A three-step treatment plan is conducted that is almost a yearlong [93]. The first level focuses on families' parenting skills and whether decisions related to eating are under family control. They learn how to help their child to gain weight. The aim of the second level is to empower patients to gain control over their eating behaviors when they reach the normal weight range. Finally, the last level focuses on individualization and developing healthy social relations both between parent and child but also in peer relations too. Behavior change is central to this model. A family-based approach is also proposed for adult patients. The Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) involves caregivers in both formulation and administration during the treatment process [94]. This motivational and client-oriented cognitive interpersonal model is developed specifically for AN patients. It focuses on eating related problems and symptoms but also obsessive and anxious-avoidant personality traits that are central to the mainte-

Cognitive behavioral therapy is the leading empirically supported treatment for BN and BED, but also there is evidence of its effectiveness in AN [83]. Enhanced CBT (CBT-E) is based on the transdiagnostic theory and is designed to treat eating psychopathology rather than being a DSM eating disorders diagnosis [6]. The word "enhanced" refers to new strategies and procedures to improve treatment outcomes and test the model in different groups (e.g., in patients, day-patients, adults,

adolescents, etc.). CBT-E can also be conducted in a multistep approach (outpatient,

#### *Anorexia Nervosa DOI: http://dx.doi.org/10.5772/intechopen.91278*

the desired level of benefit, and it is suggested that this may be due to decreased 5-HT1A receptor activity, which is a consequence of starvation [88]. Nevertheless, almost half of the AN cases report using psychotropic medications despite lack of evidence supporting their efficacy, which is also concerning due to their severe side effects [89].
