This is often a chronic relapsing and remitting condition and repeated courses of treatment, including hospital admission, may be necessary.

• Physical treatment. the first priorities are restoration of weight and correction of physical complications. Severe cases require inpatient care, and compulsory treatment under the Mental Health Act 1983 is occasionally indicated. Weight gain is best achieved by winning the patient's agreement to eat more, and skilled nurses can usually manage this, although many patients will be uncooperative at first, secretly disposing of food or vomiting. Some units use a behavioural approach in which privileges such as watching TV or having visitors are conditional on regular weight gain, but many patients find this coercive and unhelpful. Drug treatment may include the use of major tranquillizers for agitation, and appropriate specific medication for coexisting psychiatric syndromes such as depression or obsessive-compulsive disorder. If antidepres-sants are indicated, tricyclics with their appetite-stimulating properties are more appropriate than SSRIs, which can cause weight loss.

• Psychological treatment includes cognitive or supportive therapy individually or in groups, and efforts to correct abnormal body image, perhaps with the aid of measurements or photographs. Psychodynamic approaches are usually unhelpful. Family factors must also be addressed, as in the case of a girl aged 16 who developed anorexia after her achievement of eight out of nine 'A' grades at GCSE was perceived by her family as a failure because of the single 'B'. She felt that the only thing she could succeed at was the control of her weight.

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