Ethan Rhodes
Anorexia nervosa is an eating disorder that involves severe calorie restriction and often a very low body weight. It causes a fear of gaining weight and a distorted body image. Treatment for anorexia nervosa is specific to the person being treated. Hospitalization may be necessary to treat severe malnutrition or other serious medical complications. While in hospital, individuals with anorexia will receive input into their treatment plan from several medical and mental health professionals, including a psychiatrist, a medical physician, eating disorder therapists, and a registered dietician. The treatment plan may include nasogastric (NG) tube feeding, which is a temporary means of supplementing normal oral feeding for individuals whose medical stability and/or body weight continue to decline despite refeeding efforts.
| Characteristics | Values |
|---|---|
| Treatment approach | Multidisciplinary, involving medical doctors, registered dietitians, psychotherapists, psychiatrists, and eating disorder therapists |
| Treatment goals | Restoring weight and nutritional health, improving attitudes toward food, weight, and body image, and addressing underlying psychological issues |
| Treatment methods | Voluntary hospitalization, psychotherapy (talk therapy, CBT, family-based therapy, acceptance and commitment therapy), nutritional rehabilitation, meal planning, tube feeding, medication |
| Considerations | Early intervention, patient's consent and autonomy, ethical implications, monitoring for refeeding syndrome, gradual increase in caloric intake, support from loved ones |
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What You'll Learn
Nutritional rehabilitation
The first step in the nutritional rehabilitation of anorexia is to stabilise the individual's physical health. This may involve the use of feeding tubes for those with severe anorexia, which can help to alleviate distress associated with gastrointestinal complications. Nasogastric (NG) tube feeding involves inserting a tube through the nostril, down the oesophagus and into the stomach, where nutrition is delivered directly. This method supports medical stabilisation, weight gain and improved cognitive function. However, tube feeding should only be used when medically necessary and should be continuously monitored by experienced medical professionals.
Once the individual's condition is stable, they can begin the refeeding process to increase body weight and nutritional intake. This process requires therapeutic intervention and nutritional counselling to help manage behaviours and attitudes towards food and eating. Meal planning is an important aspect of this, with input from a registered dietitian nutritionist. It is important to be aware of the risk of refeeding syndrome, a dangerous metabolic imbalance that can lead to heart failure. Therefore, caloric goals should be carefully calculated by a medical team, taking into account the individual's unique metabolic needs.
In addition to nutritional rehabilitation, psychotherapy plays a crucial role in treating the underlying psychological issues contributing to the eating disorder. This includes cognitive-behavioural therapy (CBT) and family-based therapy, which can help develop healthier attitudes towards food, weight and body image, as well as improve coping mechanisms. Treatment should be tailored to the individual and may include medication for coexisting mental health conditions.
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Nasogastric tube feeding
The nasogastric tube is inserted through the patient's nostril, down the oesophagus, and into the stomach. Nutrition is then delivered directly to the stomach via the tube. The volume and frequency of nutrition are determined based on the patient's metabolic needs. This form of enteral feeding can help alleviate gastrointestinal complications related to restriction, purging, and other eating disorder behaviours. It is well-tolerated by patients with impaired gastrointestinal function and limits the physical discomfort associated with increased food intake.
It is important to note that nasogastric tube feeding should only be used when medically necessary and under the supervision of experienced medical, nursing, and nutritional professionals. The initiation of caloric intake through this method should be carefully considered, taking into account each patient's unique metabolic needs and medical complications.
In some cases, nasogastric tube feeding may be done under physical restraint when the patient is unable or unwilling to consent to the procedure. This is typically a last resort to address the life-threatening consequences of malnutrition caused by a psychiatric condition, such as a restrictive eating disorder.
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Refeeding syndrome
The risk factors for refeeding syndrome include a low body mass index (BMI), unintentional weight loss, starvation, a history of alcohol abuse, and low initial electrolyte concentrations. Patients with eating disorders, such as anorexia nervosa, are at a particularly high risk for refeeding syndrome. This is because the malnutrition that accompanies anorexia nervosa can negatively impact all systems of the body, and restoring weight and nutritional health is an essential component of treatment.
The treatment for anorexia nervosa often begins with nutritional rehabilitation to restore body weight and reverse the cognitive deficits of prolonged starvation. However, increasing caloric intake too quickly can result in refeeding syndrome. Therefore, it is important to closely monitor patients during the initial refeeding process and gradually increase caloric intake based on each patient's unique metabolic needs.
Tube feeding, such as nasogastric (NG) tube feeding, can be used as a supplement to or in place of normal oral refeeding in patients with severe anorexia. This method delivers nutrition directly to the stomach at a volume and frequency based on the patient's metabolic needs. It can help support medical stabilization, weight gain, and improved cognitive function in severely malnourished individuals, making them more ready for the psychological aspects of treatment.
Overall, the management and prevention of refeeding syndrome require careful monitoring and a gradual approach to nutritional rehabilitation, especially in high-risk populations such as patients with eating disorders.
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Ethical considerations
Treating patients with anorexia nervosa involves several ethical considerations. A fundamental principle of medical ethics is respect for individual autonomy, which means that people have the right to make decisions about their medical treatment and provide informed consent. However, in the case of anorexia nervosa, patients may be conserved if they are deemed incompetent to consent to treatment, particularly if malnutrition has impaired their cognitive abilities. This is a common issue when patients are ill enough to warrant partial hospitalization, residential treatment, or inpatient hospitalization.
When a patient's life is in immediate danger due to severe malnutrition, healthcare professionals may consider forced feeding as a last resort. While nasogastric tube feeding may be ethically justified when a patient lacks the capacity to make treatment decisions, it infringes upon their autonomy and involves medical intervention without their consent. It is also associated with physical complications such as nasopharyngeal trauma, tube misplacement, aspiration pneumonia, or esophageal perforation, and may decrease motivation to eat by mouth, resulting in tube dependency. The World Medical Association considers force-feeding a human rights violation, possibly amounting to torture.
On the other hand, some patients have described a sense of relief from enforced treatment and feeding, as the guilt and shame around eating can be so strong that being denied the choice to refuse food can relieve some of the guilt. This highlights the importance of considering each case in a nuanced and thoughtful manner, and seeking ethical committee consultations when necessary.
Nurses also face unique practical and ethical challenges when providing nasogastric tube feeding under restraint, particularly when the patient's body mass index is not immediately life-threatening. It is important to consider alternatives to enteral feeding that minimize the use of force or implement it in a more compassionate way.
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Psychotherapy
Anorexia nervosa is an eating disorder and mental health disorder where a person limits their calorie intake to an extreme, leading to malnutrition and a very low body weight. The treatment of anorexia nervosa typically involves nutritional rehabilitation to restore body weight and address the underlying mental health issues. This often includes psychotherapy, which can take several forms.
One form of psychotherapy used in the treatment of anorexia nervosa is family therapy. This approach recognises the importance of family support in the recovery process and involves putting the family in charge of the patient's nutrition. The Maudsley Method is one example of family-based therapy for anorexia. In some cases, family group psychoeducation has been found to be as effective as family therapy in helping newly diagnosed patients gain weight, while also being more cost-effective.
Interpersonal psychotherapy (IPT) is another approach that focuses on improving relationships and communication, which may help reduce symptoms of the eating disorder. IPT can be particularly useful when used in combination with other treatments, such as tube feeding.
Psychodynamic psychotherapy involves exploring the root causes of anorexia nervosa as a key to recovery. This type of therapy aims to address the negative thoughts and feelings about eating, weight, and body image that underlie the disorder.
Cognitive behavioural therapy (CBT) is also used in the treatment of anorexia nervosa. CBT can help patients challenge the eating disorder mindset and encourage the consumption of fear foods. It is often tailored to the individual and combined with other treatments, such as nutritional rehabilitation, to address both the psychological and physiological aspects of the disorder.
Supportive psychotherapy is another approach that may be provided by experienced clinicians following a detailed treatment manual. This type of therapy focuses on normalising eating through smart food selection and educating patients on the quantities of food needed to gain weight.
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Frequently asked questions
Anorexia is an eating disorder that involves severe calorie restriction and often a very low body weight. It causes a fear of gaining weight and a distorted body image.
Treatment for anorexia involves nutritional rehabilitation to restore body weight and reverse the cognitive deficits of prolonged starvation. This is done under the supervision of a medical team, which commonly includes a medical doctor, a registered dietitian nutritionist, a psychotherapist, and a psychiatrist.
Hospitalisation may be necessary to treat severe malnutrition or other serious, life-threatening physical conditions that have occurred due to anorexia. Hospitalisation can be voluntary or involuntary.
Nasogastric (NG) tube feeding is used to supplement normal oral feeding for individuals whose medical stability and/or body weight continue to decline despite refeeding efforts. Tube feeding can also reduce the risk of refeeding syndrome by gradually supplementing nutrition and vitamins.
Refeeding syndrome is a dangerous metabolic imbalance that can lead to heart failure. It occurs when caloric intake is increased too quickly, resulting in a sudden shift in fluids and electrolytes.
