Anorexia nervosa and bulimia nervosa are mental illnesses and disorders of eating behaviour; their treatment must therefore cover both aspects. There are neither pre-established rules nor fixed programmes that suit all families or all cases. There is as much variety among patients as among parents or family dynamics; generalisations therefore run the risk of unduly simplifying such a complex and risky problem. This means that, in choosing treatment, one must take into account both the criteria of effectiveness established in the scientific field and its feasibility or appropriateness in the particular circumstances.

Introduction

On the medical, psychopathological and interpersonal levels, anorexia nervosa is an often serious and complex condition. Its treatment requires interdisciplinary care of these different aspects. It has been agreed that the minimum period for assessing the results of a treatment is four years. According to the report Practice Guidelines for Eating Disorders of the American Psychiatric Association, published in 1993 (1), the best therapeutic results are linked to nutritional recovery, accompanied by family and individual therapies. It is indisputable that weight restoration must be the first objective for the severely malnourished patient, because not only does it save their life, but it also improves their personality and mood disorders, as well as obsessional thinking and body image distortion.

Types of treatment and controversies

There are controversies in this field over whether patients should be hospitalised. These criteria vary according to institutions and countries. Behavioural programmes have proved more effective in reducing the length of hospitalisation. However, the speed of weight gain during hospitalisation in no way guarantees a good long-term outcome. Nasogastric tube feeding and parenteral nutrition are used only exceptionally, when the patient’s life is in danger, given the risks of their forced use.

Recent studies have shown that flexible behavioural programmes, which make use of rest at home, may be more beneficial than the previous ones, because they foster the patient’s collaboration as well as their sense of participation and control.

Day hospital programmes can be a valid option, but they require the patient to be motivated to take part, to agree with the objectives of the treatment and to have the capacity to relate within a group setting. This last condition generally excludes the anorexic patient, whose low self-esteem and hypersensitivity to the comments of others mobilise a great deal of anxiety in the group. Group treatment seems to offer more risks than benefits.

Outpatient treatment is recommended as the first option for patients who have a good social support network and who are metabolically stable. There is general agreement that the patient and her family must be included in the treatment from the outset.

It is also necessary for them to receive information about the illness and about the patient’s condition, as well as about the relationship between the symptoms of starvation and those of anorexia nervosa. When the parents are hypercritical, it is better to see them first without the patient, until they are finally able to take part constructively in family therapy.

Advantages of family treatment

The first controlled study (2), which compares the effectiveness of family therapy with that of individual therapy, concludes that family therapy is more effective in patients with anorexia nervosa aged 18 or under and whose illness has lasted less than 3 years, both for improvement of the illness and for the prevention of relapse. The same was subsequently demonstrated (3) in chronic patients, with an average duration of illness of 7 years.

It is therefore concluded that family therapy has a radically superior effect, both on recovery and on reducing the duration of anorexia nervosa.

In patients over 18, the results are not as conclusive, but they suggest that family therapy is more useful when anorexia nervosa began during adolescence and when there has been greater closeness between the patient and her family. Most experts consider family therapy to be indispensable when children and young adolescents are concerned. Likewise, couple therapy appears useful for married patients.

The report mentioned (3) adds that psychodynamic or psychoanalytic therapy is generally ineffective in severely malnourished patients, but that it may be useful when, after recovery, personality disorders still persist. Some also advocate cognitive-behavioural therapies, to help maintain healthy eating behaviour.

As for psychopharmacological medication, there are few controlled studies, and none concerns a population of children or adolescents.

These studies conclude that the majority of patients with anorexia nervosa do not improve with medication.

Because of the high prevalence of substance abuse among patients with eating disorders, some attempt to treat these conditions with the addiction model. There is, however, no report on the results of applying this model, either in the short or in the long term. It is surprising that, in our setting, this approach applied to a day hospital programme has spread so widely, when it does not currently have recognised scientific validity.

The treatment of bulimia nervosa

As for the treatment of bulimia nervosa, hospitalisation is rarely necessary: only in cases of suicidal or clinical risk. The treatment most often chosen is outpatient treatment. The day hospital option is considered for patients who do not respond to outpatient treatment and whose eating behaviour is completely out of control.

It is established that treatment which includes nutritional re-education and, frequently, psychotherapy sessions from the outset is more effective.

So far, studies seem to indicate that cognitive-behavioural techniques and simple behavioural techniques, such as the food diary, are the most useful for reducing symptoms, a reduction generally obtained during the first 2 to 4 months of treatment. However, because of the psychopathology of these patients, as well as the family conflict and imbalance produced by bulimic behaviour, most psychotherapeutic orientations can play an important role in the long-term recovery of these patients.

Psychoanalytic therapies can only be useful after the patient has been able to control the symptom, and exclusively in carefully selected cases. Family therapy, on the other hand, has proved effective in many series, which is probably due in part to the higher level of overt conflict that exists in these families.

Self-help groups were originally created to fill a professional void, since information was scarce and specialised professional resources few; these groups could therefore be regarded as a valid alternative to professional care. At present, however, there are no studies demonstrating the effectiveness of self-help groups, even though some patients seem to benefit from the network they establish there. These groups must nevertheless never be used as the sole form of treatment, but only as an auxiliary therapy, because bulimic patients must be treated by professionals competent in this field, capable of carefully examining the psychological aspects of each case.

Antidepressant medication can be useful in the treatment of bulimia nervosa, but only as a complement. Its use is recommended particularly in patients who present symptoms of depression, anxiety, obsessions or certain impulse control disorders. To prevent relapse, individual psychotherapy is advised. Family therapy should be considered whenever possible, especially in the case of adolescents or older patients who persist in conflictual relationships with their family of origin or with their partner.

If there is abuse of chemical substances, this must be treated beforehand.

The report concludes by advising against, at the beginning, treatments centred on abstinence from bulimic behaviour, and stresses the need to take clinical and psychological issues into account as well.

Conclusions

I chose to approach the subject of the treatment of eating disorders by presenting the most current research on the topic, rather than by setting out the results of treatments with my own sample of patients.

I considered it necessary to approach the question in this way because of the great publicity that the media have given to this subject through well-known cases. In this regard, a clarification is called for concerning the proposal of a day hospital based on the self-help group: while all treatments have something to offer in approaching such a complex problem, we fortunately know today that some therapies are more appropriate than others, and that each case must be assessed with caution and specificity. That is why we must avoid Procrustean beds as regards diagnostic uniformity, simplicity of interpretation and, above all, therapeutic orthodoxy.