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Zealand clinical practice guideline for the management of anorexia nervosa (2003) Pierre Beumont, Phillipa Hay and Rochelle Beumont for the
RANZCP Multidisciplinary Clinical Practice Guideline Team
for the Treatment of Anorexia Nervosa

Objective: To provide a summary of the Royal Australian and New
Zealand College of Psychiatrists (RANZCP) Clinical Practice Guideline for
the Management of Anorexia Nervosa (AN).

Conclusions: Anorexia nervosa affects only a small proportion of the
Australian and New Zealand population but it is important because it is a
serious and potentially life-threatening illness. Sufferers often struggle with AN
for many years, if not for life, and the damage done to their minds and bodies
may be irreversible. Anorexia nervosa is characterized by a deliberate loss
of weight and refusal to eat. Overactivity is common. Approximately 50% of
patients also use unhealthy purging and vomiting behaviours to lose weight.
There are two main areas of physical interest: the undernutrition and mal-
nutrition of the illness and the various detrimental weight-losing behaviours
themselves. Basic psychopathology ranges from an over-valued idea of high
salience concerning body shape through to total preoccupation and eventually
to firmly held ideas that resemble delusions. Comorbid features are frequent,
especially depression and obsessionality. It is inadvisable in clinical practice to
apply too strict a definition of AN because to do so excludes patients in the early
stage of the illness in whom prompt intervention is most likely to be effective.
The best treatment appears to be multidimensional/multidisciplinary care,
using a range of settings as required. Obviously, the medical manifestations
of the illness need to be addressed and any physical harm halted and reversed.
It is difficult to draw conclusions about the efficacy of further treatments. There
is a paucity of clinical trials, and their quality is poor. Furthermore, the stimuli
for developing AN are varied, and the psychotherapy options to address these
problems need to be tailored to suit the individual patient. Because there is no
known ‘chemical imbalance’ that causes the illness, no one drug offers relief.
There is a high rate of relapse, and some patients are unable to recover fully.
Because AN is a psychiatric illness, a psychiatrist should always be involved in
its treatment. All psychiatrists should be capable of assuming this responsibility.

Australasian Psychiatry
Because cognitive behavioural methods are generally accepted as the best modeof therapy, a clinical psychologist should also be involved in treatment. Becausemedical manifestations are important, someone competent in general medicine Pierre Beumont
should always be consulted. The optimal approach is multidisciplinary or at Professor of Psychiatry, Royal Prince Alfred Hospital and the least multiskilled, with important contributions from psychologists, general Department of Psychological Medicine, University of Sydney, Sydney, NSW, Australia.
practitioners, psychiatric nurses, paediatricians, dietitians and social workers. Phillipa Hay
Department of Psychiatry, University of Adelaide, Adelaide, Key words: chronicity, depression, malnutrition, obsessionality, purging.
Rochelle Beumont
Consultant Project Researcher, Wesley Private Hospital, Sydney,
INTRODUCTION
roposing clinical practice guidelines (CPGs) for anorexia nervosa June 2003
Correspondence: Professor Pierre Beumont, Department of
(AN) poses several particular problems in addition to those Psychological Medicine, D06 University of Sydney, NSW 2006, encountered with other clinical guidelines: definitions; the multi- disciplinary approach required for optimal treatment; the persistence of
illness from childhood and adolescence well into other health professionals to provide optimal care.
adult life; the severity of the illness; and the paucity The principal therapist may well be a clinical psychol- of controlled randomized studies from which to make ogist, paediatrician, general practitioner or dietician.
recommendations. Notwithstanding the inevitable Further, too often AN is considered to be only an limitations of CPGs, this document provides an adolescent disorder. In fact it often starts prior to overview of the available evidence to guide clinical puberty and persists through adolescence into adult life (average duration approx. 5 years). There areinvariably problems of transition as the patient devel- Definitions
ops (or fails to develop) from adolescence to maturity.
Anorexia nervosa is an eating, or perhaps better, Anorexia nervosa frequently becomes chronic or dieting disorder, and needs to be distinguished from disordered eating, such as that contributing to obes-ity or part of unusual syndromes such as pica or CURRENT TREATMENT EVIDENCE
ruminative disorder. Anorexia nervosa, bulimia ner- The purpose of this section is not to promote vosa (BN) and atypical eating disorders not otherwise unconditionally the concept of ‘best’ treatment, or to specified (EDNOS) are psychiatric illnesses recognized preclude treatments for which there are no rand- as part of a special category in Diagnostic and Statis- omized controlled trials (RCTs). ‘Insufficient evi- tical Manual of Mental Disorders (4th edn; DSM-IV) dence’ for treatments is not the same as ‘no evidence’ and International Statistical Classification of Diseases or ‘evidence of ineffectiveness’, and established clini- and Health-related Problems (10th edn; ICD-10). Our cal consensus opinions are valid in the absence of commission from the College was to deal with AN, other levels of evidence. Unless otherwise specified, and specifically exclude BN, presumably because studies cited here are at least from level [II] evidence, there are excellent reviews of the latter disorder, applying the National Health and Medical Research particularly that of Fairburn and Wilson (in the book A Guide To Treatments That Work). But EDNOS israther different. Many EDNOS patients have binge Inpatient versus outpatient or day-patient
eating disorder (as yet poorly understood) or disor- treatment of the underweight patient
ders that are secondary to other psychiatric illnesses For those patients in whom the illness is severe (e.g. depression), or have unusual and perhaps bizarre enough to consider inpatient care but not severe conditions, which are unique, hence are not relevant enough for this to be essential, comprehensive out- to this document. However, a large number of EDNOS patient or day-patient treatment has been found to patients are those in the process of developing AN, or be at least as effective, if not more so. Outpatient those in whom the illness is in partial remission.
treatment is considerably cheaper, less intrusive, and Obviously both these groups need to be included.
has greater adherence, hence is to be preferred. The Overview of the clinical epidemiology
benefits of both forms of treatment appear to increaseover time. Inpatient care is mandatory at times of Eating disorders are a group of common illnesses acute medical crisis, rapid weight loss or physical that impose a considerable burden on health care.
Although AN is a low-prevalence disorder (lifetimerisk 0.2–0.5% of women, approx. half that of schizo- Family therapy versus individual therapy or no
phrenia), it is a very serious condition, with a mortal- specific therapy
ity rate higher than any other psychiatric illness and In the stage of weight restoration
a suicide rate higher than that of major depression.
Its seriousness is often not appreciated.
Family therapy was found to be no more effectivethan individual therapy: In 37 adolescents (11– GENERAL MANAGEMENT ISSUES
20 years) with DSM-III-R-defined anorexia nervosa,who all received common medical treatment and There is general consensus that a multiskilled and dietary advice, behavioural family systems therapy June 2003
multidisciplinary approach is optimal utilizing cogni- was found to be associated with greater weight gain tive, behavioural, and motivational enhancement and more frequent resumption of menses than ego- therapies (psychologists), nutritional supervision orientated individual therapy. However, there was no and counselling (dietitians), family and individual difference in attenuation of eating disorder attitudes, therapy (psychotherapists), skilled nursing care, and adequately trained family doctors (and in some cir-cumstances, paediatricians and physicians). However, Two studies compared outpatient individual and despite the multidimensional facets of AN’s presenta- family psychotherapy to outpatient group psycho- tion that often leads to it being an ‘orphan’ condition therapy, inpatient treatment (one study), and with no discipline taking responsibility, AN is pri- assessment only or ‘routine care’ for new adult refer- marily a psychiatric illness, and every psychiatrist rals to a specialist unit. There was significantly better should be capable of treating AN and of involving weight maintenance and psychological and social Australasian Psychiatry

adjustment at 2 years in the psychotherapy groups.
(300 mg day–1) found no significant differences Poor prognosis was associated with prior low weight, between groups although weight gain appeared better treatment non-compliance and self-induced vomit- in the fluoxetine group. This finding is supported by ing. Those in the assessment-only group had the least Clomipramine
Family therapy versus individual supportive therapy in
A 16-patient study on the effect of 50 mg daily of the prevention of relapse
clomipramine to a placebo over 8 weeks found there Family therapy is directed to global family function- was little effect on ultimate outcome. Clomipramine ing while counselling is restricted to empowering leads to increased hunger, appetite and energy intake family members to assume responsibility for the and there was a suggestion of better weight main- patient’s behaviour. Family therapy appears favour- tenance at follow up. Caveats include the small able for adolescent patients with early onset and numbers and relatively low dose of clomipramine.
short history of AN, while those patients with late- Growth hormone
onset anorexia appear to do better with individualsupportive therapy.
Growth hormone (0.05 mg kg–2day) therapy to hastenmedical stabilization in patients undergoing re- Family therapy versus family counselling
feeding has been evaluated. The growth hormone Outcomes of a pilot trial in this topic suggest that group had shorter hospital stay (not significant) and both therapies are equally effective. There was a trend reached a stable state with respect to cardiovascular towards better improvement in the separated family function (absence of orthostasis by pulse) in a shorter therapy group (76% good/intermediate global out- time (p < 0.02). There was no difference in rates of come ratings) compared to the conjoint therapy group (47% good/intermediate outcome).
Cyproheptadine
Pharmacotherapy
A number of studies have looked at the effect of daily Cisapride
doses of cyproheptadine on weight gain. The conclu-sions from these trials suggest that the medication One inpatient study found that there were no vari- may have an effect for non-bulimic patients, in terms ances in weight gain for patients prescribed cisapride of weight gain and in some psychological measures versus placebo but other differences were found, (e.g. attenuating the thin ideal). However, there were namely subjects with cisapride were hungrier and reported problems of hypersomnia, and stomatitis showed more subjective improvement. However, and hypersomnia led to the withdrawal of patients findings from a study conducted on outpatients were suggestive of improved weight gain and acceleratedgastric emptying in treated versus placebo group.
Zinc supplementation
Of note, though, are the problems with cardiac side- The use of zinc supplementation (100 mg daily of effects (serious cardiac arrythmias) of cisapride, zinc gluconate) to increase rate of weight gain has which have led to its limitation in Australia to use for gastroparesis under a consultant physician’s author-ity only. Hence it is no longer used for AN.
Clonidine
A 1987 trial found no effect for clonidine in a RCT of Antidepressants
four treatment-resistant inpatients. Low participation In one published study of fluoxetine (up to 60 mg day–1, mean: 56.0 mg) as augmentation therapy therewas no evidence of a beneficial effect on the outcome Anti-psychotics
Australasian Psychiatry
measure of weight gain, symptom severity scores, Pimozide has been found to enhance weight gain in depression or general psychiatric symptoms. In a a study of 18 inpatients on a behavioural programme.
placebo-controlled RCT of 5 weeks of amitriptyline Conclusions cannot be drawn on the use of sulpiride (mean dose: 115 mg day–1) all patients did poorly. A because of the possibility of a type II error in the trial 1995 study on the use of either nortriptyline (n = 7, concerning this drug. There have been several enthu- 75 mg day–1) or fluoxetine (n = 15, 60 mg day–1) in siastic anecdotal reports of the efficacy of olanzapine addition to psychological therapies (nutritional coun- in respect to weight gain and reversing anorexic selling and cognitive–behavioural therapy), found that weight gain and anxiety reduction were greaterin the nortryptyline group and that there were Lithium
no between-group differences in eating disorder or A 4-week crossover placebo controlled trial in 16 June 2003
depressive symptom severity. Small numbers limit inpatients (aged 12–32, mean: 19.8 years) on a conclusions. A further study by the same authors specialist behaviour programme reported minimal investigating fluoxetine (60 mg day–1) or amineptine adverse effects, and greater weight gain in weeks
3 and 4 in the lithium group. The mean plasma Comparisons of different individual and
other psychotherapies
Dietary advice sessions may increase weight gain, Cannabis
while combined individual and family psychotherapy α9THC α-9-tetrahydrocannabinol (7.5–30 mg day–1) may assist patients with sexual and social adjustment.
compared to diazepam (3–15 mg day–1) in patients all For adult patients with AN, both cognitive analytical on a behavioural group programme with nutritional therapy and educational behavioural treatment may counselling was not effective and there was more bring about good or intermediate recovery in terms of nutritional outcome, but the former is seen as slightlypreferable because patients reported significantly Naltrexone
greater subjective improvement. For adolescents,there is a slight trend in favour of family systems A 6-week trial of naltrexone (100–200 mg b.d.) in a therapy over ego-orientated individual therapy in mixed group of BN and bingeing AN outpatients, terms of weight gain and maternal communication.
found significant reductions in binge–purging in thetreatment group. Subjects were blinded, but they Treatments for osteoporosis in anorexia nervosa
In a non-blinded trial of oestrogen (with progestin)versus no replacement only those with low body Discharge at normal weight versus discharge at
weight (<70%) appeared to benefit from oestrogen.
below normal weight
In a trial of oral dehydroepiandrosterone (DHEA) a Patients discharged while severely underweight have 50-mg dose restored physiologic hormonal levels.
higher rates of re-hospitalization and are more symp- Markers showed a decrease in bone reabsorption and tomatic than those who achieve normal weight at an increase in bone formation. There were no signifi- cant changes in bone mineral density at any site, norany adverse effects reported.
Bed-rest versus supervised exercise, lenient versus
Psychological treatments that may be beneficial
strict weight restoration programmes
but which have no empirical backing
No clear conclusions were drawn from comparison of Motivational therapy
a specialist graded exercise programme following The goal of motivational interviewing is to facilitate inpatient care with standard treatment (although the patients’ readiness to change. Although using type II error was a possibility). A second study [III-2] strategies to enhance motivation to change is intui- comparing lenient and strict operant conditioning tively compelling in the psychological treatment of programmes found no difference in weight gain, but AN, it should be noted that there is no published several practical advantages of the more lenient pro- empirical evidence supporting their use.
gramme. A third study showed that brief (i.e. a fewdays) reward programmes were beneficial in promot- CONCLUSIONS AND
RECOMMENDATIONS
Specialist versus non-specialist programmes
Given the quality of evidence available (most notablythe small size and short duration of most trials) on the A 1992 study [III] comparing mortality rates in treatments for AN, dogmatism is best avoided. Obvi- two cohorts of AN patients, followed for a mean of ously more research needs to be undertaken. Based on 20 years, from a specialist and a non-specialist centre the current findings there is evidence to suggest that found that standardized and crude mortality rates some treatment of a general nature for AN results in were higher in those treated in a non-specialist unit.
lower mortality than no treatment at all, and is there-fore to be recommended. Family-based approaches June 2003
Cognitive–behaviour psychotherapy and behaviour
have moderate support as effective treatments for AN, therapy in treatment of anorexia nervosa
especially in younger patients who have a short his-tory of the disorder. Individual CBT also has moderate While there appears to be little difference in health support as an effective treatment, as do combined status in patients exposed to cognitive–behaviour treatments, especially an integration of psycho- therapy (CBT) versus behaviour treatment, patients dynamic and cognitive behavioural treatments, but were more likely to complete treatment or be retained also family and psychodynamic treatments.
in therapy with CBT. Compared with patients receiv-ing dietary advice, CBT subjects showed improve- There is widespread agreement in the current clinical ments in eating disorder and depressive symptom and research literature that multidimensional, multi- severity, and body mass index. All those receiving disciplinary treatment approaches are preferential dietary advice only ‘dropped out’ of treatment.
for effective treatment. Treatment usually needs to be Australasian Psychiatry
multidimensional in the sense that: (i) comprehen- the various teams for the mental health practitioner version of the guidelines, as well sive assessments are done (i.e. physical, psycho- as the consumer and carer consultants, are acknowledged with their affiliations in thecomprehensive version in the College journal.
logical, psychosocial, developmental and familyhistories); (ii) multiple treatment modalities are con- sidered (i.e. medication, nutrition, and individual,group and family psychotherapies); and (iii) multiple Details of the studies cited and their references are given in the full version of theClinical Practice Guidelines, to be published in the Australian and New Zealand Journal interventions are all considered (i.e. behavioural, of Psychiatry and on the College website http://www.ranzcp.org.au. Further recom- cognitive–behavioural, psychodynamic, and inter- American Psychiatric Association. Practice Guidelines for the Treatment of Eating Disorders. American Journal of Psychiatry 2000; 150: 207–228.
Treatment may also be multidisciplinary in the sensethat the services of psychiatrists, primary care physi- Beumont PJV, Russell JD, Touyz SW. Treatment of anorexia nervosa. Lancet 1993; 341:
cians, psychologists, registered dietitians, nurses, and social workers may all be utilized in a comprehensive, Garner DM, Garfinkel PE. Handbook of Treatment for Eating Disorders, 2nd edn. New coordinated manner. Obviously such treatment approaches need to be administered in a holistic, Mitchell E. Eating disorders. In: Pomeroy C, Mitchell JE, Roerig J, Crow S, eds. Medical Complications of Psychiatric Illness. Washington DC: American Psychiatric Associa-tion, 2001.
Touyz SW, Garner DM, Beumont PJV. The inpatient management of the adolescent patient with anorexia nervosa. In: Steinhausen HC, ed. Eating Disorders in Adol- This CPG was funded by the National Mental Health Strategy, Commonwealth escence: Anorexia and Bulimia Nervosa. New York: Walter de Gruyter/Aldine Department of Health and Ageing. The authors are solely responsible for the document but they used material provided by a number of different writing teams, that wasprepared after wide consultation throughout Australia and New Zealand, and with the Wilson GT, Fairburn CG. Treatment for eating disorders. In: Nathan PE, Gorman JM, eds.
input of several overseas authorities. The convenors of the consortium, members of A Guide to Treatments That Work. Oxford: Oxford University Press, 1998.
Australasian Psychiatry
June 2003

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