Atypical Anorexia nervosa is characterized by a set of observable behaviors, whose objective is weight loss.

Development Of The Disorder

3 possible large areas of vulnerability:

  1. Area of permanent general vulnerability: belonging to an overprotective and rigid family in whose environment the patient has little initiative of his own; coexistence of a high level of aspiration in life, together with a feeling of insufficiency to reach the high goals; lack of skills to deal with stressful situations.
  2. Area of temporary general vulnerability: interpersonal conflicts; intense experiences of failure; the presence of menarche; increasing physical appearance of an adult person.
  3. Specific area of vulnerability to try to lose weight: having a mother, sister or another significant person who is obese, being subjected to a powerful social influence regarding the “advantages” of being thin, being told by significant people that she is “fat”, the existence of a mother or sister with anorexia.

Two ways that can contribute to the development of the problem:

Interaction between permanent and temporary general vulnerability leads to the development of perception of loss of control, fear of losing control and exacerbation of low self-esteem.

The specific vulnerability to try to lose weight, when it coincides with moments of temporary general high vulnerability, encourages the person to start carrying out behaviors to lose weight. When the result is weight loss, the behavior is reinforced:

Intrinsic: subjective perception of control, the achievement of a proposed goal, increased self-esteem, or avoidance and escape from being obese.

Extrinsic: praise from significant people, pleasant comments, number of conversations regarding weight loss.

The action of reinforcement can lead to double learning:

  • that weight-loss behaviors are rewarding, leading to their future repetition.
  • that being thin is rewarding, which favors the fear of gaining weight and increases the likelihood of behaviors to lose weight.

Consolidation And Maintenance

Psychological Treatment Of Atypical Anorexia Nervosa

The most common behaviors to lose weight are; restricting food intake, controlling calories, taking amphetamines to reduce appetite, exercising, using laxatives, diuretics, and voluntarily vomiting.

The gratification obtained by the patient as a result of weight loss (extrinsic and intrinsic variables), reinforces the probability of occurrence of behaviors, which consolidate the maintenance of the problem.

But weight loss is not the only consequence of behavior. Other consequences: starvation, deterioration of lifestyle (social isolation), consolidation of inadequate food patterns.

These consequences lead to frequent adverse emotional responses (feelings of guilt and self-reproach, depression), which strengthen the perception that weight loss is the only stable way to achieve gratification, also contributing to the consolidation and maintenance of the problem.

Symptoms Of Atypical Anorexia Nervosa

Cases of anorexia nervosa in which compulsive food intake and vomiting are present.

The behavior of vomiting voluntarily leads to weight loss and other consequences that contribute to the strengthening of this behavior.

In addition, they lead to the learning that desired weight control is possible, without the need to restrict food intake, which makes it possible to curb appetite as well as anxiety.

The process of compulsive food intake and subsequent vomiting increases the perception of control over the body’s own regulation, reinforcing the process itself, and contributes to the consolidation and maintenance of the entire mechanism, and the problem of anorexia in general.

Procedure And Methods

The objective of behavioral evaluation must be multiple.

In principle, it is necessary to focus on the functional analysis of the problem, in order to know the behaviors used, their frequency, their history and their consequences, including their current weight and progression, the presence or not of menstruation, the daily functioning of the patient, their eating habits, etc.

  • Know the degree of vulnerability, exploring areas of possible general vulnerability (permanent and temporary), and specifically to try to lose weight.
  • Know the patient’s opinion, motivation, and expectations regarding therapy (frequent negative predisposition).

Information can be obtained from various sources: patient, family, nursing professionals, therapist.


  • Slade’s ” A Short Anorexic Behaviour Scale.”
  • Goldberg’s” Anorexia-Related Attitudes Questionnaire”.
  • Garner’s ” Eating Attitudes Test.”
  • Offer’s ” Self-Image Questionnaire.”
  • Garner’s ” Eating Disorder Inventory.”

These methods are often more useful in the field of research than in the clinical field. In each specific case, methods can be developed for the self-recording of data, or the recording by an observer.

Psychological Treatment

Psychological Treatment

General Considerations

Treatment of anorexia is a complex procedure for 2 reasons :

  1. The difficulty of the problem.
  2. The usual lack of patient cooperation.

The appropriate patient/therapist relationship, in this context, is a crucial element, and confrontations with the patient regarding their thoughts, beliefs, and perceptions should be avoided, which could endanger the continuity of the intervention. It is not appropriate to try to move too fast. Psychological intervention can be distributed in 2 phases:

  1. Strategies to regulate the patient’s weight and prepare for the second phase: it is usually carried out on a hospital basis.
  2. Weight maintenance and reduction of patient vulnerability.

Behavioral Strategies To Increase Weight And Eliminate Harmful Behaviors

Most experts agree that the first aim should gain weight to a level that allows the recurrence of menstruation.

It is carried out almost always in the hospital environment.

  • It includes procedures based on operating conditioning (as Gull in 1873, treated a patient separating her from her family until she gained weight).

A method can be used to meet the following characteristics:

  • From a situation of deprivation, the patient obtains what he or she has been deprived of contingent weight gain or food intake. It is preferable to use weight gain, because it is more objective, to avoid discussions with the doctor, not to give rise to deception, and to prevent after reinforcement behaviors to lose weight.
  • A mixed reinforcement program can be used in which the main reinforcement front is weight gain and, at the same time, a complementary (non-alternative) way of contingent reinforcement to the appropriate food intake.
  • Hospitalization itself implies deprivation of the normal life of the patient, which ceases when the patient reaches the ideal weight agreed in advance.
  • It could be applied in other areas, such as the family environment, but with greater difficulty in controlling environmental contingencies.

In addition to operational strategies, these programs include other strategies:

  • Provide the patient with extensive dietary information that allows them to healthily control their own diet.
  • Give you regular feedback on your progress regarding weight and diet.

Strategies To Control Anxiety And Fear

You can use systematic desensitization, aimed at treating the anxiety associated with the ingestion of food, fear of weight gain, changes in physical appearance, and other fears.

Other behavioral and cognitive strategies are used in many cases together:

  • Inform the patient about their problem, mechanisms and therapeutic alternatives.
  • Provide regular feedback regarding the weight achieved.
  • Define the minimum weight to be achieved, and a maximum weight not to be passed.
  • Detect dysfunctional anxiogenic thoughts of the patient and analyze them from different perspectives.
  • Situate yourself in the worst consequences (avoiding the frequent and harmful tendency to disproportionate valuation).
  • Check evidence of dysfunctional thoughts through behavioral exercises.
  • Discuss dysfunctional anxiogenic thoughts from patients ‘ weight gains (that’s when they usually appear).
  • Modify the overall objective of control of one’s own weight, image, and body, replacing it with the alternative objective of control by increasing and subsequently maintaining weight.

Strategies To Maintain Weight And Reduce Vulnerability

In order to maintain weight and reduce the patient’s vulnerability to relapses, regular, usually weekly, family-level intervention sessions can be held to address aspects such as:

  • Identify and modify inadequate family patterns of food behavior.
  • Identify and modify factors that have contributed to the vulnerability, general or specific, of the patient.
  • Prepare the family for the patient’s return home after hospitalization.
  • Train in appropriate skills for the continuity of the intervention program in the post-hospital period and interpersonal skills to improve communication.

Prepare the patient for their future outside the hospital, trying to reduce vulnerability through 2 ways:

(a) modification of dysfunctional cognitions in relation to weight, appearance, self-efficacy, self-esteem, sexual and bodily development in general, family and other issues related to the problem.

b) patient training in skills such as:

  • Select and even make an appropriate menu.
  • Eat healthily.
  • Control physical exercise.
  • Plan suitable activities, such as social contacts.
  • Identify and deal with high-risk stressful situations (bulimia episodes, dysfunctional cognitions, etc.).
  • Coping skills (relaxation or self-application of procedures with self-destructions, self-assertions, to deal with symptoms such as abdominal pain after meals or other stressful stimuli).

In spite of this therapeutic effort, in many cases it is observed that, at the time of discharge, the patient is not yet sufficiently prepared, so some specialists suggest that this phase of treatment should start even in the regimen hospital to better consolidate the weight maintenance, while defining environmental control progressively (rather than abruptly).The patient may spend short periods of time at home, which would increase).

With or without hospitalization, intervention programs at this stage should include the following strategies:

  • Contingent reinforcement to maintain weight within agreed limits.
  • Progressive patient self-control of the food diet.
  • Therapy sessions at the family level, in many cases at home during family meals to detect and modify family interactions in relation to food, helping the patient to eat autonomously.
  • A family intervention to achieve the necessary independence of the patient in their daily life and to modify other family situations that contribute to increase vulnerability (dysfunctional patterns of communication).
  • Intervention on fears regarding body weight, figure or image and loss of control.
  • Cognitive-behavioral intervention for the modification of variables that favor vulnerability (low perception of self-efficacy, low self-esteem, etc.).
  • Continuation of patient training in various activities.

Final comment: Several investigations have shown the effectiveness of psychological intervention in anorexia; however, this is an area in which research is scarce due to the difficulty of this population.


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