Anorexia in Adults (cont.)

STROBER:
What you're describing may well be anorexia nervosa, but without a diagnostic consultation, it is impossible to know this for certain. Other possibilities, again, without knowing the background of the history of these symptoms, include an anxious depression with body image disturbance and abnormalities in eating behavior. As mentioned earlier, there are some adults who develop oppressive states and anxious states which can then be complicated by changes in attitude regarding weight and shape and subsequent changes in eating behavior, but this could be a case of anorexia nervosa that has intensified over the years.

MODERATOR:
Can we talk about body image? For women and men approaching a big birthday - 40 or 50 - this can cause a great deal of anxiety about an aging body. Can that be a trigger?

STROBER:
Generally it is not. The adult concerns with health, fitness, appearance, although not unusual, represent a very different phenomena than anorexia nervosa, which is a very deep rooted and serious psychiatric illness, generally making its first appearance in adolescence. So body image concerns, per se, should not be equated with anorexia nervosa, which involves an extreme irrational fear of normal body weight and subsequent dieting, to the point of malnutrition and apparent indifference to the consequences of severe wasting.

MEMBER QUESTION:
I am 43 and struggling very badly with anorexia. My therapist wants me to go inpatient but I can not take the time off from work. What is the best outpatient treatment?

STROBER:
It isn't clear that there is a best outpatient treatment. If the fear of normalizing eating and weight gain is so great that you continue to eat restrictively, the illness will be perpetuated, in which case the only viable treatment, assuming you can tolerate its impact, will be inpatient care.

Bear in mind, that the inpatient treatment of anorexia nervosa is uniquely complicated and challenging and should be undertaken in a program specializing in this type of therapy.

MEMBER QUESTION:
I was diagnosed with anorexia at age 25 with no prior history of the disease. I found inpatient care very inadequate in terms of meeting the needs of an adult woman.

STROBER:
The inpatient treatment of anorexia nervosa cannot be undertaken in the absence of specialized expertise and a program ideally suited to the needs of individuals who suffer from this complicated illness.

"Anorexia nervosa requires intensive and prolonged treatment."

MEMBER QUESTION:
I agree. After being hospitalized for a month I was back in my apartment where I had to fend for myself. I felt it didn't really address my needs -- what to do after I was released. I had day treatment three times a week, but this was not sufficient.

STROBER:
I would agree that that is not an ideal approach to this illness. Our philosophy at UCLA is that the treatment needs to be prolonged, and for people with severe illness treatment should continue on a daily basis until the person reaches a reasonable target weight range and should remain in frequent and intensive treatment until they demonstrate reasonable ability to maintain the ability to demonstrate stability and independence in maintaining their weight.

Coming into an inpatient program and leaving prior to reaching a reasonable target weight range or transitioning to a day hospital status that doesn't allow for sufficiently intense and frequent treatment, is ill-advised.

The fact is that anorexia nervosa requires intensive and prolonged treatment, usually involving a close integration of inpatient and day hospital care in those cases, where outpatient therapy has not proved sufficient.

MEMBER QUESTION:
Why do blind weights? It seems more stressful then weighing yourself. I never understood this concept.

STROBER:
I assume that the questioner is referring to weighings in which the patient is not given direct feedback. The rationale is that the anxiety is too great and the information only further intensifies the anxiety. Whether there is or is not a rationale for blind weighing has never really been determined. I agree with the questioner that it cannot necessarily be assumed, with any reliability, that the patient has less anxiety and that this in any way facilitates treatment.

At UCLA we respect a person's wish not to know their weight, but we do not routinely use blind weighing. And have never found the patient's knowledge of their weight a deterrent to treatment.

MODERATOR:
And how do insurance companies in general respond to this? Do they treat anorexia as a physical or mental illness? Are most insurance companies willing to cover the intense and frequent treatment you suggest?

STROBER:
Our experience at UCLA, in the last several years, is that there is increasing understanding on the part of insurance carriers and support for more intensive therapy. That is not across the board, but at least with the insurance companies that we deal with frequently, there is an understanding that this illness requires prolonged and intense treatment.


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