Treatment of anorexia nervosa: Insights and obstacles Angela S. Guarda ⁎ Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA Received 24 July 2007; accepted 15 November 2007 Abstract Anorexia nervosa is a behavioral disorder characterized by ego-syntonic self-starvation, denial of illness and ambivalence towards treatment. Treatment refusal and drop-out rates are high and relapse is common. Treatment is best viewed as comprised of two phases, weight restoration and normalization of eating behavior followed by relapse prevention. Most patients verbalize a desire to change, however they seek treatment on their own terms, ideally with minimal or no weight gain. Successful treatment must therefore convince patients to overcome their drive to diet. Evidence-based data on treatment interventions for anorexia nervosa are scarce and methodological problems afflict the few published, controlled trials. Taken together, clinical expertise and data from correlational and controlled trials suggest that chronicity and adult status are associated with a worse prognosis. Outpatient family therapy is effective in weight-restoring the majority of adolescent patients whereas older patients, or those with severe medical or psychiatric comorbidity, often require intensive treatment on an inpatient eating disorders behavioral specialty unit. Correlational data suggest that weight-restored patients are less likely to relapse. Despite limitations of the current knowledge-base, several new areas of research hold promise in elucidating risk factors, in identifying the pathophysiology that sustains anorectic behavior, and in developing more targeted and effective treatments. © 2007 Elsevier Inc. All rights reserved. Keyword: Anorexia 1. Introduction Increasing rates of obesity are disproportionately affecting children and young adults (see papers by Adair and Boushey in this issue). Similarly, data suggest that prevalence rates for anorexia nervosa in the adolescent and young adult population have increased over time [1–3]. Although much less common than obesity, with a prevalence in young women of 0.3% [4], anorexia nervosa has the highest lethality of all psychiatric conditions [5] and is associated with high levels of medical and psychiatric comorbidity and with significant functional impair- ment [6]. Anorexia nervosa is difficult to treat, relapse is common, and treatment is extremely expensive and on par with that for schizophrenia [7]. Like obesity, anorexia nervosa is a heritable condition. Heritability estimates range between 56–70% [3,8,9] and genetic vulnerability is assumed to be due to multigenic effects modulated by environmental influences. Vulnerability genes may code for personality traits. Several heritable personality traits have been associated with anorexia nervosa including perfectionism and harm avoidance [10,11] and a recent large twin study identified early neuroticism as a prospective predictor of anorexia nervosa [3]. Once established, aberrant behavioral feeding patterns are likely sustained both by state-related physiological changes (e.g. starvation-induced delayed gastric transit times) and by psycho- social factors (e.g. pressure to diet). This review will cover the treatment of anorexia nervosa, a topic which has remained a major challenge to both clinicians and researchers alike for reasons intrinsic to the disorder. A description of the clinical phenomenology and outcome of anorexia nervosa will be followed by an evidence-based review of treatment interventions. Data from three separate areas – clinical expertise, correlational studies and controlled trials – will be covered. The review will conclude with promising areas of research that could help clarify pathophysiological mechan- isms sustaining anorectic behavior. Improved understanding of Available online at www.sciencedirect.com Physiology & Behavior 94 (2008) 113 – 120 ⁎ Meyer 101, Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD 21287, USA. Tel.: +1 410 955 3863; fax: +1 410 955 6155. E-mail address: Aguarda@jhmi.edu. www.elsevier.com/locate/phb 0031-9384/$ - see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.physbeh.2007.11.020