Inpatient treatment of anorexia nervosa

PAULINE S. POWERS, M.D. HENRY P. POWERS, M.S.W.

Inpatient treatment of anorexia nervosa ABSTRACT: The authors describe an inpatient program for weight

restoration in patients with anorexia nervosa, utilizing individualized behavioral management based on positive reinforcement, and accompanied by psychotherapy and family counseling or therapy. The roles of members of the treatment team are outlined. Positive treatment results were obtained in most of the 33 inpatients treated, with substantial weight gain at discharge and follow-up. Results in a smaller group of outpatients are also reported. Anorexia nervosa is a complex psychobiologic condition that has become the focus of increasing scrutiny. The mortality in untreated persons is estimated to be 10% to 15%.1 Numerous articles report investigations of the endocrine, hematologic, neurologic, and psychological features of the disease. Although its etiology remains obscure, there have been rapid advances in treatment in the last 10 years. 2•4 Early identification of the patient has improved. National re-

ferral sources are now available to direct patients to treatment centers. 5.6 This article will focus on hospital inpatient treatment, as provided in the Eating Disorders Program at the University of South Florida. This program has evolved into a pragmatic approach that can be adapted to a variety of different hospital settings not specifically designed to treat anorexia nervosa patients. This is one of several possible treatment approaches. CrisP?

Dr. Pauline Powers is associme professor and Henry Powers is clinical instructor. both in the department of p.~I'('hiatrl' at the Unil'ersity of South Florida College of Medicine. Reprint requests to Dr. POI"ers there. 12901 North 30th St.. Tampa. FL 336/2. 512

and Russe1l 8 and colleagues use an alternative method that has been described as a nursing-oriented milieu approach, in which patients are initially confined to bed and are allowed out as they gain weight. Essentially, however, this is a behavior modification approach based primarily on negative reinforcement. Our inpatient program not only requires less nursing staff but is based on positive reinforcement. Although some patients with well-known good prognostic signs,9.13 such as recent onset, less weight loss, and young age of onset, may respond to outpatient therapy, others often require hospitalization at some time during treatment. Some researchers, notably Minuchin and associates, 14 have reported successful results using family therapy in outpatients, but these are usually patients with good prognostic signs who are still in their nuclear families. Most successful treatment programs, especially at tertiary care referral centers, have included inpatient treatment.7.8 This article describes 46 patients, PSYCHOSOM ATICS

six of whom were males. Thirtythree were treated as inpatients and 13 as outpatients. The demographic and other initial characteristics of both the inpatients and the outpatients are later presented for them as a single group, since no statistically significant differences were found at the initial evaluation. The inpatient treatment program described in this report consists of individualized behavior management, psychotherapy, family counseling or therapy, and surveillance for complications from weight loss or refeeding. The results of treatment of the 13 outpatients will also be summarized. INPATIENT TREATMENT Admission and the treatment team Admission of an anorectic patient to the hospital is not the straightforward procedure that it is with most other patients. Most anorectics deny their illness, and this becomes glaringly apparent when hospitalization is recommended. The patient may refuse to go to the hospital, or the family may collude with the patient's denial by maintaining they can force the patient to eat at home. Admission may have to be negotiated with the patient, or it may be necessary to negotiate directly with the family. The latter course can be less difficult than it might seem because the patient may have so many symptoms of starvation that the family is frightened and desperate. The treatment team includes a behavioral therapist, a psychotherapist, a family therapist, a nutritionist, a nurse, and an internist or pediatrician. Communication between all members of the team is crucial; submerged conflicts within JL'L Y

19~4

• VOL 25 • "10 7

the team may undermine the program. Cohen IS described a patient whose symptoms of bingeing and vomiting worsened when there was dissension within the team. During the treatment of one of our patients, the team discovered that one member, a psychiatric resident, thought it cruel to restrict her to her room, and only after this was discussed openly were appropriate limits set by the nursing staff. One person, usually a psychiatrist who admits the patient to the hospital, assumes leadership of the team and coordinates interventions with the patient and the family. It is important that only one physician write orders. Otherwise the patient or family may convince one team member to alter some aspect of the program and thus initiate conflict within the team. The behavioral therapist, who also often is the team leader, negotiates the weight gain program with the patient, instructs the nurses about implementation of the program, evaluates reports from the nursing staff, and incorporates appropriate changes into the program. The psychotherapist meets with the patient at least three times weekly. The reason for dividing responsibility for the behavioral program and the psychotherapy is that the anorectic patient is often very angry about the behavioral program and has difficulty relating positively to the person administering it. Splitting is a common defense mechanism in anorexia nervosa patients; they often see an individual as entirely good or entirely bad and do not perceive that someone has both positive and negative traits. Initially, the behavioral therapist may be seen as bad or evil and the individual psy-

chotherapist as good or loving. This dual transference, described by Solomon and Morrison,16 can facilitate the early stage of treatment. As the patient begins to trust the psychotherapist, and as weight increases, these roles do not need to be as rigidly maintained, and eventually one therapist can monitor the weight and provide psychotherapy. The family therapist may be a separate therapist or the behavioral therapist or the individual psychotherapist. The choice depends on the results of the evaluation of family transactions. Some families may benefit from counseling rather than therapy. For example, some families are able to accept and implement direct advice about how to respond to the anorectic when he or she refuses to eat. Other families may benefit from family therapy as described by Minuchin 14 or Selvini-Palazzoli. 17 The nutritionist is an essential part of the team and should participate from the beginning in selecting a suitable dietary regimen likely to be acceptable to the patient. Most anorectics obsess about food or have spent considerable time handling it; many want to consult daily or even hourly with the nutritionist. To decrease obsessions about food and to ease the role of the nutritionist, yet still give the patient some food choices, visits from the nutritionist can be made an integral part of the behavioral program. For example, a visit from the nutritionist can be utilized as a positive reinforcement for weight gain. The role of the nursing staff is one of the most difficult and often least rewarding. One of the major advantages of the behavioral program is that it gives the nurses reasonable and consistent guidelines 513

Anorexia nervosa

to follow that may prevent constant unproductive arguments with the patient about food and weight. Nonetheless, because each patient has an individualized behavioral program, nursing implementation of the program is time-consuming. Since the nurses are often the target of the anorectic's anger, and since they rarely see that person as an outpatient, periodic progress reports are needed to foster continuing enthusiasm. The consulting internist or pediatrician assists in evaluation and follows the patient during treatment. During the initial work-up, other causes of weight loss and its consequences are evaluated. During the period of weight gain, the consultant may need to provide treatment for additional complications. Occurrences such as congestive heart failure 18 or pulmonary emboli may require temporary transfer to a different service.

Bebavioral management program The behavioral management program, also called the weight restoration program, is based on operant conditioning principles. It is a modified form of the one described by Halmi and associates. 4 For example, a patient is initially confined to a room with no visitors or phone calls, but with weight gain is able to earn privileges. On Day I, called the starting point, the patient is weighed and is asked to gain I Ib in five days; the critical day is Day 6 (Day I of the next five-day period). A patient who has gained at least I Ib earns one hour out of the room daily, one visitor for one hour during the next five-day period, and one phone call out and one in during the next five days, as well as the right to receive and send all the mail that has accumulated during 514

the previous five-day period. If the patient has not gained the entire pound, but has not lost weight from the starting point, no privileges are earned and there are no other consequences. If, however, the patient drops below the starting weight, formula meals or tube feeding are initiated until that starting weight is attained. Which negative consequence is chosen depends on the severity of the malnutrition at hospital admission; less ill patients may need only formula meals. With weight gain of at least 1 Ib during the second five-day period, privileges increase to two hours out of the room, two visitors, two phone calls in and out, and saved mail is received or sent. If the patient has not gained lib, but also has not lost weight, the previously earned daily hour out of the room is retained. As before, if the weight drops below the starting point, formula meals or tube feedings are started. Privileges during subsequent cycles increase similarly. A variation of this approach is for the patient to begin the program with no room restriction and, if all meals are consumed during a given day, to remain out of the room when desired. A person who fails to consume everything on the meal tray is then restricted to the room for the remainder of the day. Visitors, phone calls, and other privileges may be contingent on weight gains during the five-day cycles. As more is learned about the patient, he or she is encouraged to negotiate the terms of the behavioral program. For example, some patients prefer going to the lobby, or having more hours out of the room, or want to reward themselves at the end of a five-day period with a gourmet meal. One patient loved to play tennis and eventually did so

at a nearby court for each cycle in which she gained weight. During the first few cycles the patient is usually given meals calculated to allow slightly more calories than needed to gain I Ib in five days. The basal requirements are calculated from the Boothby-Berkson nomogram, 19 and 20% is added for physical activity. If formula is used it is Sustacal (I calorie/cc), offered in six divided feedings at times of the patient's choice. Fortyfive minutes are allowed for each meal alone or with others, and then the food is removed from the room.

Individual and family therapy It may initially be difficult to form an empathic relationship because the patient denies any problem. The traditional psychoanalytic stance in which the therapist is a blank screen is not effective. Often the therapist must be very supportive and may need to allow the patient to know more about him or her than usual. Reeducative psychotherapy, in which the patient is encouraged to learn to identify feelings and their relation to behavior, is often more useful than insight psychotherapy, which focuses on the causes of the anorexia. Often the first feeling to be identified is anger, and many anorectics vomit or exercise more when they are angry. Identification of this pattern may be the first step in assisting the patient to choose a less destructive response to anger. Once a therapeutic relationship is established, and the patient has learned to identify feelings and thoughts, insight-oriented psychotherapy may be possible. Awareness of symbiotic relationships or of family behavioral patterns that have inhibited development of appropriate independence may not be PSYCHOSOMATICS

sufficient for the patient to become independent. Often many significant developmental stages have been missed, and sometimes the person needs concrete assistance in progressing through these stages. This may include group therapy, day treatment, or placement in a halfway house. Family sessions are needed, at least to inform the parents about progress and to enlist their continuing support. Many parents need assistance in coping with guilt feelings, and all need advice on managing power struggles over food. Although we routinely advise family therapy and see a need for it in almost all cases, we have not been able successfully to engage many families in meaningful therapy. There have been several dramatic exceptions to this, but many families have been very resistant to entering therapy. In our work with them, we noted several common problems that probably decrease willingness to participate in family therapy. Many parents consider any psychiatric disorder in a child as evidence of their failure, are thus overwhelmed with guilt, and avoid family therapy. Other families have great difficulty nurturing suitable steps in the emerging independence of the anorectic and seem to cope by ignoring the patient's difficulties. Garfinkel and Garner 20 have described "all or none reasoning" in anorectics. With many families, this cognitive style is mirrored in their view toward independence: one is either dependent or independent. A person struggling to become independent may be ejected by the family, and unwillingness to participate in family therapy may be symbolic of this ejection. When family therapy is undertaken, the JULY 1984· VOL 25· NO 7

focus is on reestablishment of intergenerational boundaries and on identification of the thoughts and feelings manifested by individual members. When a patient is discharged from the hospital, it is usually recommended that the family avoid any involvement in the weight program and allow the therapist to take responsibility for overseeing weight. It is often very difficult for parents to comply with this request, and they may count calories as assiduously as the patient. The parents are assured that the therapist will notify them if a significant amount of weight is lost. Families that follow this advice usually experience less tension at home and experience fewer power struggles regarding eating and food.

I

PATIENT CHARACTERISTICS Diagnostic criteria Of the 40 females, 36 met all the DSM-1II 21 and Feighner22 criteria. The remaining four were 20% to 25% below their ideal body weight (lBW) but met all the other criteria and also met all of Bruch's criteria. 23 •24 Seven of the patients who met both the DSM-III and Feighner criteria did not have all three psychological criteria described by Bruch. In only 13 patients could the characteristic family interaction as described by Minuchin and associates 14 be identified. All six male patients met both the DSM-lII and Feighner criteria. Four met Bruch's psychological criteria, and two manifested the Minuchin type of family pattern. Demographic characteristics are

Table 1-Demographlc Characteristics -

l

Fema'"

Ma'"

(N D 6)

(N-40)

Age at onset Range

16.5 yr 11-25 yr

14.3 yr 13-18 yr

Average weight prior to onset Range Number (%) not atlBW 5% or more below IBW· 10% or more below IBW 5% or more above IBW· 10% or more above IBW

54.5 kg 43.2-113.6 kg 16 (40) 11 (27.5) 6 (15) 5 (12.5) 4 (10)

60.5 kg 36.4-112 kg 4 (67) 3 (50) 2 (33) 1 (17) 1 (17)

Marital status Married Divorced Single

5 1 34

Years to initial diagnosis Range Average age at clinic presentation Range

3.3 yr 5 mo-32 yr 20.3 yr 13-53 yr

J

0 0 6 1.2 yr 3 mo-3 yr 16.5 yr 14-21 yr

'The 5% or more (beloW 01 above) IBW Includes those 10% or more (beloW or above) IBW

515

Anorexia nervosa

presented in Table I. The average age at onset was somewhat lower in the male than female patients and the time until first detection of the condition was shorter. Signs and symptoms are shown in Table 2. All female patients had amenorrhea and nearly one third of them had developed it before significant weight loss. All patients, male and female, had distorted attitudes toward eating, food, or weight, and all reported troublesome obsessions about food. All the females had distortions of body image, detected either by self-description or the Draw-A-Person (DAP) test. 25 Most of them de-

scribed themselves as fat even when markedly cachectic, and the most common methods of inducing weight loss were exercise and dieting. Most of the males had exercised or dieted to lose weight. All had disturbances in body image, although its expression was usually different from that in the females. Some males complained of feeling fat, and some of feeling powerless. Several drew asexual figures on the DAP or drew a female first. Psychiatric diagnoses were made on a clinical basis following DSMIII guidelines and after weight restoration, since the cognitive signs of

Table 2-S19ns and Symptoms

I

I

Males (N=6) Average % below IBW"

Range Eating patterns Dieting Anorexic Dieting and anorexic Binge-eating Self-induced vomiting Binge-eating and vomiting Exercise to lose weight

35% 20%-59% 31

4

8

2

4

1

14

1 1

12 9

o

39

4

Medication abuse laxatives Diuretics Diet pills Amenorrhea Primary Secondary Prior to any weight loss Prior to significant weight loss

42% 31%-50%

7 1

1

1

o o

40 1 39

1 12

Average years to onset of amenorrheat

2.5 yr

'Fo, pallents under 1e, lhe 18W was determined from standardized growth charts f,om the NatIOnal Cente, for Health Statislrcs n For patIents over 1 the MetropoMan HelQht/Weight Tables were used 28

e.

tAtter onset of we'ghl loss In 35 pallents wah a rellable hIStory

semistarvation may mimic obsessive-compulsive disorders 26 (Table 3). Although all the females initially had obsessions about food, and most compulsively handled food, only half were judged to have a compulsive personality dis.order. Seven had no personality disorder. OUTCOME Hospitalized patients

Twenty-eight of the females were hospitalized for an average of 78 days, with a range of 15 days to one year. One died while hospitalized. The cause of death was not established, despite an autopsy, but a fatal arrhythmia was suspected. Two patients had juvenile-onset, insulin-dependent diabetes mellitus, and in both this diagnosis precipitated onset of weight loss. The diabetes was managed during weight gain by an endocrinologist and required nearly daily adjustments in insulin dosages. Two other patients developed congestive heart failure during weight gain. One patient recovered with fluid restriction and the other required digitalization; these individuals are described in detail elsewhere. IS Five of the males were hospitalized for an average of 49 days with a range 000 days to 72 days. None of them died. One developed congestive heart failure during refeeding IS and required digitalization. One was at a normal weight at the time of presentation to the clinic, but was hospitalized for psychological reasons. The reasons for the development of congestive heart failure in three patients are not known. Subtle signs of cardiac decompensation may occur more often than is usually recognized, especially on psychiatric wards. To avoid this complication we routinely perform (('(}ll1iIlUed)

516

PSYCHOSOMATICS

Anorexia nervosa

an ECG and echocardiogram, and determine electrolytes initially and periodically during weight restoration. Any quick weight gain (over 2 Ib in five days) is immediately investigated as is any symptom or sign such as shortness of breath or pedal edema. The results of treatment appear in Table 4. For the surviving 27 female inpatients, the average weight gain was 8.7 kg. All patients were weighed at discharge and follow-up. The length of follow-up averaged 10 months and no one was lost to it. Follow-up information was obtained during an interview by one of the authors. The average weight gain from hospital admission to follow-up was 10.4 kg. None of the females were above IBW, seven were at IBW, eight

~

were 5% to 10% below it, and 12 were more than 10% below IBW. The average weight gain at discharge for the four underweight males was 10.4 kg. At discharge, all four were more than 10% underweight. The length of follow-up averaged six months and no one was lost to it. At that time, three had maintained their discharge weight and one had gained 3 kg. Although all four were still below IBW, two weighed more than they had prior to any weight loss. This finding is explained by the fact that these two adolescents, both of whom were 14 years old, had failed to gain weight appropriate for their age prior to weight loss. In order to study the relationship between weight gain and possible psychological improvement, the

Table 3-Personallty and Family Factors

r Personality or neurotic disorders Compulsive Passive-aggressive Dysthymic SChizoid Precipitating factors None identified seemingly trivial events Psychologically significant events Family history of psychiatric disorders * Alcohol dependence Major depression Psychotic disorders Histrionic personality SChizoid personality

Females (N=40)

Males (N=6)

33

6 1 4

19 12 1 1

a 1

12 16

1 2

10

3

11

3

2 1 1 1

1 1

0 0

5 4

'Some patients had more than one relative With psychiatriC disorders. --

survlvmg patients were divided into groups according to weight gain. Group I had the best weight outcome and included patients who gained to IBW at follow-up; Group II included those who gained weight after discharge but did not achieve IBW; Group III included patients who maintained their discharge weight; and Group IV included those who lost weight after discharge. Psychological improvement at follow-up was judged to have occurred if there were insights into the causes of the weight loss or if relationships with family, friends, or therapist had improved. This judgment was made during a onehour interview with one of the authors at follow-up. At follow-up for the female~, Groups I through IV proved to have 7, 6, 10, and 4 members, respectively. In each group about half were judged improved psychologically. However, achievement of IBW did not necessarily predict improved psychological status, and one patient at IBW was worse, as she had developed overt signs of schizophrenia. At follow-up for the males, Groups I through IV had I, I, 3, and 0 members, respectively. Only one male (in Group I) was judged improved psychologically and he was at IBW; he had been hospitalized for psychological reasons rather than for weight gain. Nonhospitalized patients Twelve females were not hospitalized. Outpatient treatment had been recommended for two who were considered able to participate in psychotherapy or family therapy, but neither returned. Hospitalization was strongly advised for six; all refused, and all but one of them were lost to follow-up. Hospitaliza(colllinlledj

JULY 1984· VOL 25· NO 7

519

Anorexia nervosa

tion was recommended for another three patients, but a trial of outpatient treatment was agreed upon when they refused hospitalization. Although one of them participated meaningfully in psychotherapy, none gained weight over the course of three months. Outpatient treatment was recommended for one patient who was 25% below IBW; in six months she gained to IBW, got married, got a better job, and was intuitive in psychotherapy. Thus, as a group, only one patient is known to have gained to IBW, one may have gained to IBW, and of the remainder not lost to follow-up, none gained a significant amount of weight. One male was not hospitalized. He presented with a chief complaint of growth failure and, as an outpatient on a behavior modifica-

tion program, gained to IBW in three months. He passively accepted some interpretations but had difficulty participating meaningfully in therapy. Prognostic factors for hospitalized patients Several studies have identified factors that statistically may have prognostic implications, at least in terms of weight gain. 9 " 3 Good prognosis is associated with single marital status, higher educational achievement, employment in skilled or professional occupations, earlier age of onset and presentation, shorter duration of illness, less weight loss during illness and at presentation, good childhood adjustment, good relationship with parents, overactivity, and admission to feelings of hunger. Poor

Table 4-Treatment Results for Hospitalized Patients

I

Ma'"

Ferna'"

(N-4·)

(N-27) Average weight gain at discharge

Range Lowest % below IBW during illness

Range Relationship of IBW to discharge weight Number above IBW AtlBW 5%-10% below IBW More 'than 10% below IBW Average weight gain from discharge to follow-up

Range

8.7 kg 1.4 kg-16.3 kg

10.4 kg 9 kg-13 kg

37% 20%-59%

40% 31%-51%

0 3 6 18

0 0 0 4

1.7 kg Loss of 7.3 kggain of 12.3 kg

0.7 kg 0.3 kg

°FtIIe pehenls were hospttahzed but one was not underweIght

prognosis is associated with laxative abuse, vomiting, bulimia, anxiety during eating, previous hospitalizations, denial of illness, psychosocial immaturity, psychosomatic complaints, depressive symptoms, and obsessive-compulsive symptoms. Our results for the females were similar to those in other studies reported. Younger age at onset and at presentation were usually associated with good weight outcome. In general, the longer the length of time to diagnosis, the greater the likelihood for poor weight outcome. However, the patient who was oldest at presentation (53 years old, and 21 years old at the onset of her illness) gained to IBW. Only one of the patients who achieved IBW had been hospitalized previously. Marriage or divorce was generally associated with poor weight outcome. However, in our patients, employment in skilled occupations or attendance at college were not associated with good weight outcome. More of the patients in the poor outcome groups tended to have bulimia and/or vomiting, but overactivity was not a discriminator for groups as it was a nearly universal finding. Also, there was no consistent relationship between admission of hunger and weight outcome. Conclusions Because of the dangerous effects of starvation and weight loss, anorexia nervosa patients must frequently be hospitalized. The most effective program that we have been able to devise consists of several parts (behavior modification, individual psychotherapy, and family therapy) and requires the collaboration of several professions. T~ose patients for whom outpatient treat!emil i 1/ I/ed)

JULY 191(4· VOl. 25· NO 7

523

Anorexia nervosa

ment was initially attempted generally did not gain weight and were often lost to follow-up. Although psychological improvement did not

necessarily correlate with a good weight outcome, treatment within the hospital setting allows for simultaneous focus on weight gain as

well as on important psychodynamic or family issues and may account for the improved outcome among inpatients. 0

anorexia nervosa. Ann Intern Med 78:907909,1973. 11. Beaumonl P, George G, Smarl 0: Dieters and vomiters and purgers in anorexia nervosa. Psychol Med 6:617-622, 1976. 12. Hsu LKG, Crisp AH. Harding B: Outcome of anorexia nervosa. Lancet 1:61-65. 1979. 13. Halmi K, Goldberg SC. Casper RC, et al: Pretreatment prediclors of outcome in anorexia nervosa. Br J Psychiatry 134: 71-78. 1979. 14. Minuchin S, Rosman BL, Baker L. et al: Psychosomatic Families. Cambridge, Harvard University Press, 1978 15. Cohen Sl: Hostile interaction in a general hospital ward leading to disturbed behavior and bulimia in anorexia nervosa: I1s successful management. Postgrad Med J 54:361363.1978. 16. Solomon AP. Morrison DR: Anorexia nervosa: Dual transference therapy, Am J Psychother 26:480-489. 1972 17. Selvini-Palazzoli MS: Self-starvation. From the Intrapsychic to the Transpersonal Approach to Anorexia Nervosa. New York. Aronson, 1978. 18. Powers PS: Hearl failure during treatment of anorexia nervosa. Am J Psychiatry 139:1167-1170.1982. 19. Boothby W. Berkson J: Food nomogram, in Jolliffe N, Alperl E: The 'Performance Index' as a method for estimating effectiveness of

reducing regimens. Postgrad Med 9: 106-115. 1951. Garfinkel PE, Garner OM: Anorexia Nervosa: A Multidimensional Perspective. Montreal. Brunner/Mazel, 1982, pp 123-163. Diagnostic and Statistical Manual 01 Mental Disorders, ed 3. Washington DC, American Psychiatric Association, 1980. pp 67-69. Feighner JP, Robins E, Guze SB, et al: Diagnostic criteria for use in psychiatric research. Arch Gen Psychiatry 26:57-63. 1972 Bruch H: Eating Disorders: Obesity, Anorexia Nervosa and the Person Within. New York, Basic Books, 1973 Bruch H: Psychological antecedents of anorexia nervosa, in VlQersky RA (ed): Anorexia Nervosa. New York. Raven Press. 1977, pp 1-10. Machover K: Personality projection in the drawing of the human figure. Springfield, III. Charles C Thomas, 1957 Keys A, Brozek J. Henschel A. et al: The Biotogy ot Human Starvation. Minneapolis, University of Minnesota Press, 1950, vol 2, pp 819-853. National Center for Health Statistics. NCHS growth charts, 1976. Monthly Vital Statistics Report 25{3XSuppl):1-22, 1976. Metropolitan Life Insurance Company: New weight slandards for men and women. Stat BuI/40:1-10, 1959.

REFERENCES 1 Schwarlz OM, Thompson MG: Do anorectits get well? Current research and future needs. Am J Psychiatry 138:319-323, 1981. 2. Agras WS. Barlow DH, Chapin HN, et al: Behavior modification of anorexia nervosa. Arch Gen Psychiatry 30:279-286. 1974. 3. Liebman R. Minuchln S, Baker L: An inlegrated. program for anorexia nervosa. Am J Psychiatry 131 :432-436, 1974. 4. Halmi KA. Powers PS, Cunningham S: Treatment of anorexia nervosa with behavior modification. Arch Gen Psychiatry 32:93-96. 1975. 5. Anorexia Nervosa and Associated Diseases (ANAD). Suite 2020, 550 Frontage Road. Norlhfield. IL. 60093. (312) 831-3438. 6. American Anorexia Nervosa Association, Inc. 133 Cedar Lane. Teaneck, NJ 07666, (201) 836-1800. 7. Crisp AH: Clinical and therapeutic aspects of anorexia nervosa: A study of 30 cases. J Psychosom Res 9:67-69,1965. 8. Russell GFM: General management of anorexia nervosa and difficul1ies in assessing the efficacy of treatment, in Vigersky RA (ed): Anorexia Nervosa. New York, Raven Press, 1977,277-289. 9 Seidensticker JF, Tzagournis M: Anorexia nervosa: Clinical features and long-term follow-up. J Chron Dis 21 :361-367, 1968. 10. Halmi K, Brodland G, Loney J: Prognosis in

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527