Abstract
Anorexia nervosa is a serious and potentially fatalmental illness. The Clinical Practice Guidelines team presented a reviewof the epidemiology, course and outcome, issues in treatment and the current evidence on the treatment of anorexia nervosa. They concluded that there is insufficient evidence to support any single approach to treatment [1].
I wish to make four observations: first, although hundreds of anorexics are admitted to eating disorder units, not a single trial has been conducted in Australia in the last 10 years. Second, we are aware that 50% of patients get better, half of the remaining relapse and a great many run a chronic course [2] with multiple readmissions and death in some cases. What are the indicators for good and bad outcomes in their experience? Third, if these indicatorswere known, theywould serve to guide treatment planners in choosing adjunctive treatments such as cognitive behavioural, cognitive analytic, psychoanalytic and systems family therapy at a particular stage in refeeding programs or soon after. Given that anorexia nervosa is a complex, multifactorial and multidimensional disorder with alarming morbidity and mortality, the need for such information is urgent. Finally, the use of antidepressants and olanzapine is relegated to some non-specific role, in which case, why use them? The use of fluoxetine and olanzapine in the weight restoration and weight maintenance phases are now widely accepted practice, with the understanding that depression and psychosis is not uncommon in the clinical picture. The argument that depression in anorexia nervosa is a consequence of poor nutritional state may well be outdated, as both clinical and population-based studies have consistently revealed an increased association between major depression and anorexia nervosa [3]. The possibility that we may in fact be dealing with a particular psychosis has been suggested for some years, and, in-depthworkwith some such individuals, it closely resembles a monosymptomatic psychosis. In my clinical experience, and of others, dissociation, often unnoticed, makes for difficulties in the treatment of some anorexics.
The assessment of anorexia nervosa must take into account the presence of comorbidity, such as major depression, obsessive–compulsive disorder and delusional disorder which affect compliance and outcome, as does borderline, and obsessive–compulsive personality disorders. These facts are conspicuously absent. There is a high prevalence of obsessive–compulsive disorder in anorexia nervosa. Its prevalence may be correlated with the severity of the disorder [4]. Besides, dieting and starvation have been said to be insufficient to account for the increase in obsessive symptoms in eating disorder [5].
The medical manifestations of the illness are well covered, but the psychological facts are totally ignored. Why have there not been any controlled studies of treatments by Australian experts, given the support that is available to them? This deficit needs urgent attention. The expert team has only told us what does not work, and in doing so has not addressed the complexity of anorexia nervosa. I found the guidelines personally very unhelpful.