21 Is deep brain stimulation a treatment option for anorexia nervosa? and chronicity are very divergent. The studies reviewed, vary considerably in duration of follow-up (1–29 years), whereas outcome is influenced significantly by the duration of follow-up, with a higher mortality but also a tendency towards recovery with increasing duration of follow-up in surviving patients (13). On the other hand, chronicity is associated with poor outcome, indicating that some cases of AN are indeed treatment refractory (20). For the purpose of this article, we chose to define chronicity as an illness duration of five years or more. Patients with AN have elevated rates of lifetime diagnoses of anxiety disorders, depressive disorders, obsessive-compulsive disorder (OCD), personality disorders and substance abuse disorders (8, 9, 20). Comorbidity in eating disorders is substantial and contributes to a less favorable outcome of AN. Treatment options The therapeutic options for AN consist of different treatment-approaches that focus on weight restoration, changes in behaviour and reducing the psychological features of AN. However, evidence-based treatment for AN is very limited. There is no category A evidence and only family interventions meet category B criteria according to the NICE-guidelines (21-24). Psychotherapeutic interventions include cognitive behavioural therapy (CBT) and family therapy. A number of studies have reported that CBT after weight restoration could be effective in reducing the risk of relapse in adults with AN, but it is unknown what the efficacy is in underweight patients (see (25) for review). Variants of family therapy show a modest level of evidence with regard to efficacy in adolescents but not in adults. SSRIs are ineffective in reducing AN symptoms or restoring weight and the American Psychiatric Association does not support the use of SSRIs in the management of underweight patients with AN (25) (Treatment of patients with eating disorders, APA 2006). There is some, however weak, evidence that the use of SSRIs may help in preventing relapse in weight restored patients (26, 27). Tricyclic antidepressants seem ineffective on weight gain or improvement of AN symptoms (28, 29). For atypical antipsychotics, there are only limited data available (30). Bissada et al. conducted a double-blind, placebo-controlled trial in 34 patients with AN. Olanzapine treatment resulted in more rapid weight gain and improvement in obsessive symptoms (31). Two other randomized, controlled trials with olanzapine showed similar results (32, 33). Another study, conducted in an inpatient setting, failed to show any benefit for olanzapine on weight and psychological symptoms (34). These results indicate that olanzapine may be helpful in increasing weight and decreasing obsessive symptoms in chronic severe AN in outpatient (35), but practice guidelines do not recommend its routine use (36, 37) (American Psychiatric Association 2006). Unfortunately, there is no agreement on the definition of treatment-refractoriness in AN (38). Refractory AN is a term used in clinical psychiatry to describe cases of AN not responding to typical modes of treatment, such as psychotherapy and psychopharmacology. Strober et al. (1997) and Herzog et al. (1999) found that the possibility of recovery in AN patients with an illness duration longer than 10 years is very low (39, 40).
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