Eating Disorders 201the disorder, perhaps particularly when the individual is apprehensive
about the shift from childhood dependency to sexual maturity and adult
independence.
Although it seems natural to assume that anorexic cognitions motivate
anorexic behaviour (for example, that a preoccupation with weight leads
to excessive dieting), the reverse could also be true. In some circumstances,
self-starving behaviour may take on a life of its own. The constipation and
delayed gastric emptying associated with starvation can make the affected
individual feel full up despite eating little. In addition, starvation may have
its own rewards, perhaps in the form of extra attention or a sense of
being in control. As starvation reduces thermogenesis and insulation, the
compulsion to exercise may automatically increase in order to maintain
body temperature, thereby accelerating weight loss. In these sorts of ways,
starvation and weight loss may become self-perpetuating, with affected
individuals subsequently trying to make sense of their own addiction to
starvation by coming up with plausible but irrelevant explanations in
terms of feeling too fat. From this perspective, even if weight loss began
in response to stress or culturally sanctioned dieting, the process may
subsequently become a vicious cycle that is hard to escape.
Treatment
With suitably trained therapists, the treatment of anorexic children and
teenagers who live with their families can usually be managed on an
out-patient basis. Gradual but steady weight restoration is the first main
goal, aiming for an eventual weight within 10% of expected. This is
usually accomplished by eating modest meals more often (four to six times
per day).
Weight gain is facilitated by some combination of family therapy,
behavioural techniques and individual therapy. Family sessions aim to
promote a family restructuring that will facilitate recovery, often by
putting parents more clearly in charge of dietary intake until normal
weight control has been re-established. Evidence from randomised
controlled trials suggests that including parents as well as children in
the treatment programme is more important than the details of whether
parents and children are seen together or separately. There can be
advantages to providing group treatments for several affected families at
a time. Behavioural techniques can be used to reward adherence to diet
and successful weight gain. Individual therapy can provide a mixture
of support, cognitive restructuring, education about diet, insight and
problem-solving skills. There is no clear role for neuroleptics or appetite
stimulants, but antidepressants may have some effect on weight gain and
comorbid depression.
Prognosis
Long-term follow-ups of clinic series (almost certainly over-representing
severe cases) show that roughly 50% recover, 30% are partly improved
and 20% run a chronic course; about a fifth go on to develop affective