Cognitive behavior therapy in the posthospitalization treatment of anorexia nervosa

Emotion-focused treatments for anorexia nervosa: a systematic review of the literature

PURPOSE

The present review explores emotion-focused treatments for anorexia nervosa (AN).

METHODS

We conducted a systematic literature search across key databases (PsychINFO, PubMed/Medline, and Web of Science) prior to September 2015. Twenty studies were selected for systematic review.

RESULTS

The present review found initial evidence supporting the acceptability and feasibility of emotion-focused treatments for AN. Although preliminary results are promising, further controlled studies are necessary to establish the efficacy of emotion-focused treatments for AN.

CONCLUSIONS

Future controlled trials should compare emotion-focused treatments against each other and against other AN treatments. Future studies should also examine the mechanisms of action for the emotion-focused treatments and treatment moderators.

Effectiveness of individualized, integrative outpatient treatment for females with anorexia nervosa and bulimia nervosa

The effectiveness of an individualized outpatient program was investigated in the treatment of bulimia nervosa (BN) and anorexia nervosa (AN). Participants included 151 females who received outpatient eating disorder treatment in the partial hospitalization program, the intensive outpatient program, or a combination of the two programs. Outcome measures included the Eating Disorder Inventory (EDI-2), Beck Depression Inventory (BDI-II), frequency of binge eating and purging, and mean body weight. Findings included significant increases in weight for the AN group, reductions in binge eating frequency for the BN group, and reductions in EDI-2 and BDI-II scores and purging frequency for both groups. This study provides preliminary support for the efficacy of a multimodal program for the treatment of both anorexia nervosa and bulimia nervosa.

Motivational Text Message Intervention for Eating Disorders: A Single-Case Alternating Treatment Design Using Ecological Momentary Assessment

OBJECTIVE

This study tested a motivational text message treatment adjunct for individuals with eating disorders (EDs) who exhibited high dietary restraint/restriction.

METHOD

A replicated single-case alternating treatment design was used to examine (a) the feasibility of combining a brief motivational interview with subsequent text messages and (b) the influence of the text messages on eating behaviors and motivation to change in individuals with EDs (N=12). The protocol was 8weeks and the text messages were adjunctive to cognitive-behavioral therapy.

RESULTS

The intervention was well accepted (mean rating=7/10) and feasible within the context of monetary compensation (mean daily monitoring compliance =91%). Text messages did not impact behavioral outcomes: dietary restraint and kilocalorie intake. They had mixed effects on motivation to change dietary restraint, measured by the Readiness and Motivation Questionnaire (RMQ). When receiving text messages, RMQ precontemplation scores (desire to restrict) significantly increased, indicating decreased motivation; however, action scores (effort toward reducing dietary restraint) significantly increased, indicating increased motivation. These effects were moderated by weight status. Underweight individuals (n=4; body mass index [BMI]<19.0) reported increased ambivalence-that is, an increased desire to restrict and increased action toward reducing restriction-in response to the text messages. Normal weight participants (n=8; BMI>19.0) reported only increased action toward reducing restriction in response to the text messages.

DISCUSSION

These data demonstrate text messages are a potentially feasible and acceptable treatment adjunct and may be effective at increasing motivation to change for normal weight individuals, while their influence on underweight patients is more complex. These findings provide a foundation for future research in technology-based motivational interventions for EDs and offer preliminary evidence for using these methods among normal weight individuals.

Neurobiologically informed treatment for adults with anorexia nervosa: a novel approach to a chronic disorder

Anorexia nervosa (AN) is a severe and debilitating disorder with significant medical and psychological sequelae. To date, there are no effective treatments for adults, resulting in high rates of chronicity, morbidity, and mortality. Recent advances in brain imaging research have led to an improved understanding of etiology and specific neurobiological mechanisms underlying symptoms. Despite this, there are no treatments focused on targeting symptoms using this empirically supported mechanistic understanding of the illness. Updated treatment approaches focused on targeting neurobiological mechanisms underlying core AN symptomatology are necessary to improve treatment out-comes for this population. Neurobiologically Enhanced With Family Eating Disorder Trait Response Treatment (NEW FED TR) is a neurobiologically informed treatment targeting key temperament constructs associated with the illness through the delivery of psychoeducation and skills training to patients and nominated carers.

Emotion regulation training to reduce problematic dietary restriction: An experimental analysis

Evidence suggests that emotion regulation may be a process relevant to problematic dietary restriction. However, emotion regulation has not been evaluated as an intervention target across a range of restriction severity. This study utilized an experimental design to examine whether targeting emotion regulation reduced problematic dietary restriction. Within a self-identified restrictive sample (n = 72), the effects of an emotion regulation condition (i.e., emotion regulation training) were compared to those of a control condition (i.e., nutrition information training) on dietary restriction indices (i.e., effort to reduce intake on a progressive ratio task, work towards an alternate reinforcer on a progressive ratio task, intake by dietary recall) following a stressor. Exploratory analyses of potential moderators (i.e., restraint, BMI, binge eating and purging status, emotion regulation difficulties) were conducted to examine whether these factors affected the impact of training on dietary restriction. No significant main effects of condition were detected on any outcome measure. However, results were moderated by BMI status. Participants with lower BMIs exerted less effort towards dietary restriction following the emotion regulation condition versus the control condition (p = 0.02). Results suggest that targeting emotion regulation may help to reduce problematic dietary restriction among lower weight individuals.

Effectiveness of psychosocial interventions in eating disorders: an overview of Cochrane systematic reviews

Eating disorders are psychiatric conditions originated from and perpetuated by individual, family and sociocultural factors. The psychosocial approach to treatment and prevention of relapse is crucial. To present an overview of the scientific evidence on effectiveness of psychosocial interventions in treatment of eating disorders. All systematic reviews published by the Cochrane Database of Systematic Reviews - Cochrane Library on the topic were included. Afterwards, as from the least recent date of these reviews (2001), an additional search was conducted at PubMed with sensitive search strategy and with the same keywords used. A total of 101 primary studies and 30 systematic reviews (5 Cochrane systematic reviews), meta-analysis, guidelines or narrative reviews of literature were included. The main outcomes were: symptomatic remission, body image, cognitive distortion, psychiatric comorbidity, psychosocial functioning and patient satisfaction. The cognitive behavioral approach was the most effective treatment, especially for bulimia nervosa, binge eating disorder and the night eating syndrome. For anorexia nervosa, the family approach showed greater effectiveness. Other effective approaches were interpersonal psychotherapy, dialectic behavioral therapy, support therapy and self-help manuals. Moreover, there was an increasing number of preventive and promotional approaches that addressed individual, family and social risk factors, being promising for the development of positive self-image and self-efficacy. Further studies are required to evaluate the impact of multidisciplinary approaches on all eating disorders, as well as the cost-effectiveness of some effective modalities, such as the cognitive behavioral therapy. RESUMO Transtornos alimentares são doenças psiquiátricas originadas de e perpetuadas por fatores individuais, familiares e socioculturais. A abordagem psicossocial é essencial para o tratamento e a prevenção de recaídas. Apresentar uma visão geral das evidências científicas sobre a efetividade das intervenções psicossociais no tratamento de transtornos alimentares. Foram incluídas todas as revisões sistemáticas publicadas no Banco de Dados de Revisões Sistemáticas da Cochrane Library. Posteriormente, a partir da data menos recente destas revisões (2001), realizou-se uma busca adicional no PubMed, com estratégia de busca sensibilizada e com os mesmos descritores utilizados antes. No total, foram incluídos 101 estudos primários e 30 revisões sistemáticas (5 revisões sistemáticas da Cochrane), metanálises, diretrizes ou revisões narrativas da literatura. Os principais desfechos foram remissão de sintomas, imagem corporal, distorção cognitiva, comorbidade psiquiátrica, funcionamento psicossocial e satisfação do paciente. A abordagem cognitivo-comportamental foi o tratamento mais efetivo, principalmente para bulimia nervosa, transtorno da compulsão alimentar periódica e síndrome do comer noturno. Para anorexia nervosa, a abordagem familiar demonstrou maior efetividade. Outras abordagens efetivas foram psicoterapia interpessoal, terapia comportamental dialética, terapia de apoio e manuais de autoajuda. Além disso, houve um número crescente de abordagens preventivas e promocionais que contemplaram fatores de risco individuais, familiares e sociais, sendo promissoras para o desenvolvimento da autoimagem positiva e autoeficácia. São necessários mais estudos que avaliem o impacto de abordagens multidisciplinares em todos transtornos alimentares, além da relação custo-efetividade de algumas modalidades efetivas, como a terapia cognitivo-comportamental.

Applying evidence-based management to anorexia nervosa

AIM

This paper considers how the three principles of evidence based practice (clinical expertise, scientific evidence, and patient preference) can be applied to the complexity of treatment for anorexia nervosa AN.

METHOD

A narrative review of the evidence of these three domains is presented. Clinical cases are used to illustrate how the formulation and management can be put into practice at different stages of illness.

RESULTS

The management of anorexia nervosa is complex. First, individuals with the illness do not regard the manifestations of the illness as a source of concern rather they are embraced and integrated into their identity. This contrasts to the reaction of other people who are terrified by the overt signs of ill health. Thus engagement into treatment is problematic. Second, the core symptom restricted eating, produces malnutrition which impacts on brain, body, and the social network. Thus a mixture of psychological and physical problems gradually accumulates over the course of the illness. This means that the treatment targets increase over time.

CONCLUSION

Thus treatment has to work with motivation and readiness to change and tackle the various domains of ill health.

Cognitive Behavioral Therapy for Anorexia Nervosa: An Update

Cognitive behavioral therapy (CBT) for anorexia nervosa (AN), based on Beck's cognitive theory, was developed in a "generic" form in the early eighties. In recent years, however, improved knowledge of the mechanisms involved in maintaining eating disorder psychopathology has led to the development of a "specific" form of CBT, termed CBT-E (E = enhanced), designed to treat all forms of eating disorders, including AN, from outpatient to inpatient settings. Although more studies are required to assess the relative effectiveness of CBT-E with respect to other available treatments, the data indicate that in outpatient settings it is both viable and promising for adults and adolescents with AN. Encouraging results are also emerging from inpatient CBT-E, particularly in adolescents, and clinical services offering CBT-E at different levels of care are now offered in several countries around the world. However, CBT-E requires dissemination in order to become widely available to patients.

Anorexia nervosa: aetiology, assessment, and treatment

Anorexia nervosa is an important cause of physical and psychosocial morbidity. Recent years have brought advances in understanding of the underlying psychobiology that contributes to illness onset and maintenance. Genetic factors influence risk, psychosocial and interpersonal factors can trigger onset, and changes in neural networks can sustain the illness. Substantial advances in treatment, particularly for adolescent patients with anorexia nervosa, point to the benefits of specialised family-based interventions. Adults with anorexia nervosa too have a realistic chance of achieving recovery or at least substantial improvement, but no specific approach has shown clear superiority, suggesting a combination of re-nourishment and anorexia nervosa-specific psychotherapy is most effective. To successfully fight this enigmatic illness, we have to enhance understanding of the underlying biological and psychosocial mechanisms, improve strategies for prevention and early intervention, and better target our treatments through improved understanding of specific disease mechanisms.

Individual psychological therapy in the outpatient treatment of adults with anorexia nervosa

BACKGROUND

Anorexia nervosa is a disorder with high morbidity and significant mortality. It is most common in young adult women, in whom the incidence may be increasing. The focus of treatment has moved to an outpatient setting, and a number of differing psychological therapies are presently used in treatment. This is an update of a Cochrane review which was last published in 2008.

OBJECTIVES

To assess the effects of specific individual psychological therapies for anorexia nervosa in adults or older adolescents treated in an outpatient setting.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group Specialised Register (CCDANCTR) (16 July 2014). This register includes relevant randomised controlled trials from: the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). We screened reference lists of all included studies and sent letters to identified, notable researchers requesting information on unpublished or ongoing studies.

SELECTION CRITERIA

All randomised controlled trials of one or more individual outpatient psychological therapies for adults with anorexia nervosa, as defined by DSM-5 or similar international criteria.

DATA COLLECTION AND ANALYSIS

We selected a range of outcome variables, including physical state, severity of eating disorder attitudes and beliefs, interpersonal function, and general psychiatric symptom severity. Continuous outcome data comparisons used the mean or standardised mean difference (MD or SMD), and binary outcome comparisons used the risk ratio (RR). Two review authors (PH and AC or ST) extracted data independently.

MAIN RESULTS

We identified 10 trials from the search, with a total of 599 anorexia nervosa participants, and included them in the review. Seven had been identified in the previous versions of this review and we now include three new trials. We now deem one previously identified ongoing trial to be ineligible, and six ongoing trials are new for this update. Two of the 10 trials included children. Trials tested diverse psychological therapies and comparability was poor. Risks of bias were mostly evident through lack of blinded outcome assessments (in 60% of studies) and incomplete data reporting (attrition bias).The results suggest that treatment as usual (TAU) when delivered by a non-eating-disorder specialist or similar may be less efficacious than focal psychodynamic therapy. This was suggested for a primary outcome of recovery by achievement of a good or intermediate outcome on the Morgan and Russell Scale (RR 0.70, 95% confidence interval (CI) 0.51 to 0.97; 1 RCT, 40 participants; very low-quality evidence). However there were no differences between cognitive analytic therapy and TAU for this outcome (RR 0.78, 95% CI 0.61 to 1.00; 2 RCTs, 71 participants; very low-quality evidence), nor for body mass index (BMI). There were no differences in overall dropout rates between individual psychological therapies and TAU.Two trials found a non-specific specialist therapy (Specialist Supportive Clinical Management) or an Optimised TAU delivered by therapists with eating disorder expertise was similar in outcomes to cognitive behaviour therapy (BMI MD -0.00, 95% CI -0.91 to 0.91; 197 participants, low-quality evidence). When comparing individual psychological therapies with each other, no specific treatment was consistently superior to any other specific approach. Dietary advice as a control arm had a 100% non-completion rate in one trial (35 participants). None of the trials identified any adverse effects. Insufficient power was problematic for the majority of trials.

AUTHORS' CONCLUSIONS

There was a suggestion in one trial that focal psychodynamic therapy might be superior to TAU, but this is in the context of TAU performing poorly. An alternative control condition of dietary advice alone appeared to be unacceptable, but again this is based on just one trial. Owing to the risk of bias and limitations of studies, notably small sample sizes, we can draw no specific conclusions about the effects of specific individual psychological therapies for anorexia nervosa in adults or older adolescents. Larger RCTs of longer treatment duration and follow-up are needed.

Practice parameter for the assessment and treatment of children and adolescents with eating disorders

This Practice Parameter reviews evidence-based practices for the evaluation and treatment of eating disorders in children and adolescents. Where empirical support is limited, clinical consensus opinion is used to supplement systematic data review. The Parameter focuses on the phenomenology of eating disorders, comorbidity of eating disorders with other psychiatric and medical disorders, and treatment in children and adolescents. Because the database related to eating disorders in younger patients is limited, relevant literature drawn from adult studies is included in the discussion.

Weighing patients within cognitive-behavioural therapy for eating disorders: How, when and why

While weight, beliefs about weight and weight changes are key issues in the pathology and treatment of eating disorders, there is substantial variation in whether and how psychological therapists weigh their patients. This review considers the reasons for that variability, highlighting the differences that exist in clinical protocols between therapies, as well as levels of reluctance on the part of some therapists and patients. It is noted that there have been substantial changes over time in the recommendations made within therapies, including cognitive-behavioural therapy (CBT). The review then makes the case for all CBT therapists needing to weigh their patients in session and for the patient to be aware of their weight, in order to give the best chance of cognitive, emotional and behavioural progress. Specific guidance is given as to how to weigh, stressing the importance of preparation of the patient and presentation, timing and execution of the task. Consideration is given to reasons that clinicians commonly report for not weighing patients routinely, and counter-arguments and solutions are presented. Finally, there is consideration of procedures to follow with some special groups of patients.

First results of a refeeding program in a psychiatric intensive care unit for patients with extreme anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is associated with a high mortality rate. This study describes a compulsory re-feeding program established in Munich for extremely underweight patients.

METHODS

The contract between the patient and the therapeutic team included mandatory inpatient status, establishment of guardianship and compulsory re-feeding with a percutaneous gastric feeding tube, as indicated. The predefined target was a body mass index (BMI) of 17 kg/m(2). Data on the first 68 patients with AN are presented.

RESULTS

65 (95.6%) patients were female and mean age at admission was 26.5 ± 8.5 years. BMI increased from 12.3 ± 1.4 kg/m(2) at admission to 16.7 ± 1.7 kg/m(2) at discharge. Thirty-two (47.1%) patients had the restrictive subtype (ANR) and 36 (52.9%) had the binging and purging subtype (ANBP). Duration of illness before admission (p = .004), days of treatment until discharge (p = .001) and weight increase (p = .02) were significantly different between subgroups in favor of patients with ANR. Also, seasonal differences could be found. Comparison of feeding methods showed that percutaneous tube feeding was superior. Almost half of the patients were treated with psychotropic medication. To date, however, the number of patients included in this program is too small to assess rare complications of this acute treatment program and long term outcomes of AN.

CONCLUSIONS

An intensive care program for severely ill AN patients has been successfully established. Besides averting physical harm in the short term, this program was designed to enable these patients to participate in more sophisticated psychotherapeutic programs afterwards. To our knowledge, this is the first such program that regularly uses percutaneous feeding tubes.

Pre-treatment attachment anxiety predicts change in depressive symptoms in women who complete day hospital treatment for anorexia and bulimia nervosa

OBJECTIVES

Individuals with eating disorders are prone to depressive symptoms. This study examines whether depressive symptoms can change in women who complete intensive day treatment for anorexia and bulimia nervosa (BN), and whether these changes are associated with pre-treatment attachment insecurity.

DESIGN

Participants were 141 women with anorexia nervosa restricting type (n = 24), anorexia nervosa binge purge type (n = 30), and BN (n = 87) who completed a day hospital treatment programme for eating disorders. They completed a pre-treatment self-report measure of attachment, and a pre-treatment and post-treatment self-report measure of depressive symptoms.

RESULTS

Participants experienced significant reductions in depressive symptoms at post-treatment. Eating disorder diagnosis was not related to these improvements. However, participants lower in attachment anxiety experienced significantly greater improvement in depressive symptoms than those who were higher in attachment anxiety.

CONCLUSIONS

These results suggest that clinicians may tailor eating disorders treatments to patients' attachment patterns and focus on their pre-occupation with relationships and affect regulation to improve depressive symptoms.

PRACTITIONER POINTS

That depressive symptoms can decrease in women who complete day hospital treatment for anorexia and BN. That improvements in depressive symptoms do not vary according to eating disorder diagnosis in these women. That patients who complete treatment and who have higher attachment anxiety experience less improvements in depressive symptoms compared to those lower in attachment anxiety. That clinicians may attend to aspects of attachment anxiety, such as need for approval and up-regulation of emotions, to improve depressive symptoms in female patients with eating disorders.

Anorexia nervosa: A fresh perspective

Anorexia nervosa is currently presented as a pathologised, psycho-medical feminine phenomenon through aetiological rationalisations and theories. Research results indicate that there have been no improvements in treatment outcomes for anorexia for over 50 years, except, possibly, with forms of family therapy for adolescents. This situation can be seen as critical and calls for alternative ways of understanding anorexia, and consequent different approaches to psychotherapy for persons in relationship with anorexia. This article critically explores these issues, and suggests that such circumstances offer opportunities for alternative post-structuralist approaches for informing different understandings of and working with anorexia in collaborative relational arrangements where the voices of persons in relationship with anorexia are honoured and heard.

Best nutrition counseling practices for the treatment of anorexia nervosa: a Delphi study

OBJECTIVE

To use Delphi methodology to evaluate the extent to which a panel of registered dietitians (RDs) who treat anorexia nervosa (AN) concur on parameters related to nutrition counseling for AN.

METHOD

The twenty-one panelists who participated in this study: (i) were RDs (ii) had specialized in nutritional counseling for eating disorders for 5 years or more, and (iii) had Internet access at home or work. Over a 10-week period (between 8/2013 and 11/2013), panelists completed three iterative questionnaires. Questionnaire 1 included 12 open-ended questions regarding nutrition counseling for patients with AN. Subsequent questionnaires were developed based on a content analysis of responses to the first questionnaire, and panelists were asked to rank their level of agreement with these items.

RESULTS

Consensus was defined as 85% agreement and was achieved for 47 (35.3%) of the 133 items included in the third questionnaire. Items achieving consensus described nutrition counseling approaches that are applicable to all patients with AN, and their wording typically allowed for consideration of individual needs. Some items that did not achieve consensus reflected approaches for which individual tailoring may be necessary depending on age, stage of illness, and other patient factors. Consensus was also not shown for approaches for which there is little evidence.

DISCUSSION

Nutritional counseling intervention for AN has some consensus features, but the need for individualization was apparent. A stronger evidence-base for nutritional counseling interventions for AN would provide guidance and facilitate greater consistency among RDs regarding how to best care for this patient population.

Eating disorder symptoms and quality of life: where should clinicians place their focus in severe and enduring anorexia nervosa?

OBJECTIVE

The aim of this study was to examine the relationship between quality of life (QoL), weight, and eating disorder symptoms across treatment in individuals with severe and enduring anorexia nervosa (SE-AN).

METHOD

Participants were 63 adult females with SE-AN presenting to an outpatient, multisite randomized clinical trial. QoL was assessed using three well-validated QoL questionnaire measures, the EDQOL, SF-12, and WSAS. Participants' weight and severity of symptoms was assessed by Eating Disorder Examination (EDE) and weekly BMI change.

RESULTS

Predictors of QoL were evaluated in the context of concurrent, prospective,1 and lagged mixed-effects models. Changes in both BMI and EDE were found to significantly affect current and future QoL ratings.

DISCUSSION

Findings suggest that improvements in QoL may be dependent on symptom change and weight gain. Treatments seeking solely to improve QoL may be unlikely to produce lasting change and clinicians should maintain a focus on weight and behavioral symptoms as much as on improvements in QoL.

Psychotherapy in anorexia nervosa: What does the absence of evidence mean?

Psychological treatment in anorexia nervosa (AN) is disheartening. Psychotherapy is the “treatment of choice” for adults though this recommendation is grounded on the absence of good quality clinical studies. This paper seeks to address the question of why improvements in the psychological treatment of AN have been thwarted, and why one of the best treatments available for adult patients is specialist supportive clinical management that has entered the stage through the backdoor of nonspecific supportive treatments originally serving as a placebo treatment assigned in randomized clinical trials to control for non-specific aspects of true psychosocial treatments. The possibility that most of the psychopathological features that characterise the AN symptoms profile could be best understood as the direct consequences of emaciation would enhance the utility of research with animal models for generating new hypothesis to improve AN treatment.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders

OBJECTIVES

This clinical practice guideline for treatment of DSM-5 feeding and eating disorders was conducted as part of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Clinical Practice Guidelines (CPG) Project 2013-2014.

METHODS

The CPG was developed in accordance with best practice according to the National Health and Medical Research Council of Australia. Literature of evidence for treatments of anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), other specified and unspecified eating disorders and avoidant restrictive food intake disorder (ARFID) was sourced from the previous RANZCP CPG reviews (dated to 2009) and updated with a systematic review (dated 2008-2013). A multidisciplinary working group wrote the draft CPG, which then underwent expert, community and stakeholder consultation, during which process additional evidence was identified.

RESULTS

In AN the CPG recommends treatment as an outpatient or day patient in most instances (i.e. in the least restrictive environment), with hospital admission for those at risk of medical and/or psychological compromise. A multi-axial and collaborative approach is recommended, including consideration of nutritional, medical and psychological aspects, the use of family based therapies in younger people and specialist therapist-led manualised based psychological therapies in all age groups and that include longer-term follow-up. A harm minimisation approach is recommended in chronic AN. In BN and BED the CPG recommends an individual psychological therapy for which the best evidence is for therapist-led cognitive behavioural therapy (CBT). There is also a role for CBT adapted for internet delivery, or CBT in a non-specialist guided self-help form. Medications that may be helpful either as an adjunctive or alternative treatment option include an antidepressant, topiramate, or orlistat (the last for people with comorbid obesity). No specific treatment is recommended for ARFID as there are no trials to guide practice.

CONCLUSIONS

Specific evidence based psychological and pharmacological treatments are recommended for most eating disorders but more trials are needed for specific therapies in AN, and research is urgently needed for all aspects of ARFID assessment and management.

EXPERT REVIEWERS

Associate Professor Susan Byrne, Dr Angelica Claudino, Dr Anthea Fursland, Associate Professor Jennifer Gaudiani, Dr Susan Hart, Ms Gabriella Heruc, Associate Professor Michael Kohn, Dr Rick Kausman, Dr Sarah Maguire, Ms Peta Marks, Professor Janet Treasure and Mr Andrew Wallis.

Predicting clinical outcome using brain activation associated with set-shifting and central coherence skills in Anorexia Nervosa

BACKGROUND

Patients with Anorexia Nervosa (AN) have neuropsychological deficits in Set-Shifting (SS) and central coherence (CC) consistent with an inflexible thinking style and overly detailed processing style, respectively. This study investigates brain activation during SS and CC tasks in patients with AN and tests whether this activation is a biomarker that predicts response to treatment.

METHODS

FMRI data were collected from 21 females with AN while performing an SS task (the Wisconsin Card Sort) and a CC task (embedded figures), and used to predict outcome following 16 weeks of treatment (either 16 weeks of cognitive behavioral therapy or 8 weeks cognitive remediation therapy followed by 8 weeks of cognitive behavioral therapy).

RESULTS

Significant activation during the SS task included bilateral dorsolateral and ventrolateral prefrontal cortex and left anterior middle frontal gyrus. Higher scores on the neuropsychological test of SS (measured outside the scanner at baseline) were correlated with greater DLPFC and VLPFC/insula activation. Improvements in SS following treatment were significantly predicted by a combination of low VLPFC/insula and high anterior middle frontal activation (R squared = .68, p = .001). For the CC task, visual and parietal cortical areas were activated, but were not significantly correlated with neuropsychological measures of CC and did not predict outcome.

CONCLUSION

Cognitive flexibility requires the support of several prefrontal cortex resources. As previous studies suggest that the VLPFC is important for selecting context-appropriate responses, patients who have difficulties with this skill may benefit the most from cognitive therapy with or without cognitive remediation therapy. The ability to sustain inhibition of an unwanted response, subserved by the anterior middle frontal gyrus, is a cognitive feature that predicts favorable outcome to cognitive treatment. CC deficits may not be an effective predictor of clinical outcome.

Inpatient cognitive behavior therapy for adolescents with anorexia nervosa: immediate and longer-term effects

INTRODUCTION

Inpatient treatment for anorexia nervosa is often successful in restoring body weight, but a high percentage of patients relapse following discharge. The aim of the present study was to establish the immediate and longer-term effects of a novel inpatient program for adolescents that was designed to produce enduring change.

METHOD

Twenty-seven consecutive patients with severe anorexia nervosa were admitted to a 20-week inpatient treatment program based on the enhanced cognitive behavior therapy (CBT-E). The patients were assessed before and after hospitalization, and 6 and 12 months later.

RESULTS

Twenty-six patients (96%) completed the program. In these patients, there was a substantial improvement in weight, eating disorder features, and general psychopathology that was well maintained at 12-month follow-up.

CONCLUSION

These findings suggest that inpatient CBT-E is a promising approach to the treatment of adolescents with severe anorexia nervosa.

Mapping the evidence for the prevention and treatment of eating disorders in young people

ABSTRACT

Eating disorders often develop during adolescence and young adulthood, and are associated with significant psychological and physical burden. Identifying evidence-based interventions is critical and there is need to take stock of the extant literature, to inform clinical practice regarding well-researched interventions and to direct future research agendas by identifying gaps in the evidence base.

AIM

To investigate and quantify the nature and distribution of existing high-quality research on the prevention and treatment of eating disorders in young people using evidence mapping methodology.

METHOD

A systematic search for prevention and treatment intervention studies in adolescents and young adults (12-25 years) was conducted using EMBASE, PSYCINFO and MEDLINE. Studies were screened and mapped according to disorder, intervention modality, stage of eating disorder and study design. Included studies were restricted to controlled trials and systematic reviews published since 1980.

RESULTS

The eating disorders evidence map included 197 trials and 22 systematic reviews. Prevention research was dominated by trials of psychoeducation (PE). Bulimia nervosa (BN) received the most attention in the treatment literature, with cognitive behavioural therapy (CBT) and antidepressants the most common interventions. For anorexia nervosa (AN), family based therapy (FBT) was the most studied. Lacking were trials exploring treatments for binge eating disorder (BED) and eating disorder not otherwise specified (EDNOS). Relapse prevention strategies were notably absent across the eating disorders.

CONCLUSIONS

Despite substantial literature devoted to the prevention and treatment of eating disorders in young people, the evidence base is not well established and significant gaps remain. For those identified as being at-risk, there is need for prevention research exploring strategies other than passive PE. Treatment interventions targeting BED and EDNOS are required, as are systematic reviews synthesising BN treatment trials (e.g., CBT, antidepressants). FBTs for AN require investigation against other validated psychological interventions, and the development of relapse prevention strategies is urgently required. By systematically identifying existing interventions for young people with eating disorders and exposing gaps in the current literature, the evidence map can inform researchers, funding bodies and policy makers as to the opportunities for future research.

Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in outpatients with anorexia nervosa (ANTOP study): randomised controlled trial

BACKGROUND

Psychotherapy is the treatment of choice for patients with anorexia nervosa, although evidence of efficacy is weak. The Anorexia Nervosa Treatment of OutPatients (ANTOP) study aimed to assess the efficacy and safety of two manual-based outpatient treatments for anorexia nervosa--focal psychodynamic therapy and enhanced cognitive behaviour therapy--versus optimised treatment as usual.

METHODS

The ANTOP study is a multicentre, randomised controlled efficacy trial in adults with anorexia nervosa. We recruited patients from ten university hospitals in Germany. Participants were randomly allocated to 10 months of treatment with either focal psychodynamic therapy, enhanced cognitive behaviour therapy, or optimised treatment as usual (including outpatient psychotherapy and structured care from a family doctor). The primary outcome was weight gain, measured as increased body-mass index (BMI) at the end of treatment. A key secondary outcome was rate of recovery (based on a combination of weight gain and eating disorder-specific psychopathology). Analysis was by intention to treat. This trial is registered at http://isrctn.org, number ISRCTN72809357.

FINDINGS

Of 727 adults screened for inclusion, 242 underwent randomisation: 80 to focal psychodynamic therapy, 80 to enhanced cognitive behaviour therapy, and 82 to optimised treatment as usual. At the end of treatment, 54 patients (22%) were lost to follow-up, and at 12-month follow-up a total of 73 (30%) had dropped out. At the end of treatment, BMI had increased in all study groups (focal psychodynamic therapy 0·73 kg/m(2), enhanced cognitive behaviour therapy 0·93 kg/m(2), optimised treatment as usual 0·69 kg/m(2)); no differences were noted between groups (mean difference between focal psychodynamic therapy and enhanced cognitive behaviour therapy -0·45, 95% CI -0·96 to 0·07; focal psychodynamic therapy vs optimised treatment as usual -0·14, -0·68 to 0·39; enhanced cognitive behaviour therapy vs optimised treatment as usual -0·30, -0·22 to 0·83). At 12-month follow-up, the mean gain in BMI had risen further (1·64 kg/m(2), 1·30 kg/m(2), and 1·22 kg/m(2), respectively), but no differences between groups were recorded (0·10, -0·56 to 0·76; 0·25, -0·45 to 0·95; 0·15, -0·54 to 0·83, respectively). No serious adverse events attributable to weight loss or trial participation were recorded.

INTERPRETATION

Optimised treatment as usual, combining psychotherapy and structured care from a family doctor, should be regarded as solid baseline treatment for adult outpatients with anorexia nervosa. Focal psychodynamic therapy proved advantageous in terms of recovery at 12-month follow-up, and enhanced cognitive behaviour therapy was more effective with respect to speed of weight gain and improvements in eating disorder psychopathology. Long-term outcome data will be helpful to further adapt and improve these novel manual-based treatment approaches.

FUNDING

German Federal Ministry of Education and Research (Bundesministerium für Bildung und Forschung, BMBF), German Eating Disorders Diagnostic and Treatment Network (EDNET).

The role of reproductive hormones in the development and maintenance of eating disorders

Much remains to be understood about the etiology of eating disorders. There is substantial evidence that reproductive hormones, specifically estrogens, play a direct role in normal food intake. Evidence is increasing that the reproductive hormones play a role in the abnormal food intake associated with eating disorders. For example, there is an inverse association between estradiol and eating disorder symptoms. Preliminary studies also suggest that hormone augmentation may be a beneficial adjunct to the standard treatment of choice for eating disorders. However, research is limited, so definitive conclusions about the benefit of hormone augmentation in treatment cannot be drawn. Future research, with a focus on translational studies, should continue to explore the role of reproductive hormones in the vulnerability to and maintenance of eating disorders.

What does remission tell us about women with eating disorders? Investigating applications of various remission definitions and their associations with quality of life

OBJECTIVE

To compare remission rates, determine level of agreement and identify quality of life (QoL) distinctions across a broad spectrum of remission definitions among patients with eating disorders (ED).

METHODS

Women (N=195; 94 AN, 24 BN, and 77 EDNOS) from inpatient and partial hospital ED programs participated in a study of treatment outcomes. Remission rates were evaluated with percentages, kappa coefficients identified level of agreement and Mann-Whitney-Wilcoxon tests with Bonferroni corrections determined differences in quality of life between remitted and not remitted patients by remission definition.

RESULTS

Depending on remission definition used, the percent of remitted patients varied from 13.2% to 40.5% for AN, 15.0% to 47.6% for BN and 24.2% to 53.1% for EDNOS. Several definitions demonstrated "very good" agreement across diagnoses. Remission was associated with higher quality of life in psychological, physical/cognitive, financial and work/school domains on a disease-specific measure, and in mental but not physical functioning on a generic measure.

CONCLUSIONS

Remission rates vary widely depending on the definition used; several definitions show strong agreement. Remission is associated with quality of life, and often approximates scores for women who do not have an eating disorder. The ED field would benefit from adopting uniform criteria, which would allow for more accurate comparison of remission rates across therapeutic interventions, treatment modalities and facilities. We recommend using the Bardone-Cone criteria because it includes assessment of psychological functioning, was found to be applicable across diagnoses, demonstrated good agreement, and was able to distinguish quality of life differences between remitted and not remitted patients.

The Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA): Development, Key Features, and Preliminary Evidence

Anorexia nervosa (AN) is a severe mental disorder that affects mainly young females. In adults with a well-established form of the illness, it is hard to treat. In 2006, we proposed a maintenance model of AN, combining intra- and interpersonal factors and we have recently refined this model. The model encompasses four main maintaining factors (a thinking style characterized by rigidity, detail focus, and a fear of making mistakes; an avoidant emotion processing and relational style; positive beliefs about the use of anorexia for the person [pro-anorexia beliefs]; and a response of close others to the illness characterized by high expressed emotion and enabling of and accommodation to the illness). In this article, we describe how the model has been translated into a novel treatment for AN and the preliminary evidence supporting this. Implications for clinical practice and research are discussed.

Update on the treatment of anorexia nervosa: review of clinical trials, practice guidelines and emerging interventions

BACKGROUND

Anorexia nervosa is a potentially deadly psychiatric illness that develops predominantly in females around puberty but is increasingly being recognized as also affecting boys and men and women across the lifespan. The aim of this environmental scan is to provide an overview of best practices in anorexia nervosa treatment across the age spectrum.

METHOD

A triangulation approach was used. First, a detailed review of randomized controlled trials (RCTs) for anorexia nervosa published between 1980 and 2011 was conducted; second, clinical practice guidelines were consulted and reviewed; third, information about RCTs currently underway was sourced. This approach facilitated a comprehensive overview, which addressed the extant evidence base, recent advances in evidence and improvements in treatment, and future directions.

RESULTS

The evidence base for the treatment of anorexia nervosa is advancing, albeit unevenly. Evidence points to the benefit of family-based treatment for youth. For adults no specific approach has shown superiority and, presently, a combination of renourishment and psychotherapy such as specialist supportive clinical management, cognitive behavioral therapy, or interpersonal psychotherapy is recommended. RCTs have neither sufficiently addressed the more complex treatment approaches seen in routine practice settings, such as multidisciplinary treatment or level of care, nor specifically investigated treatment in ethnically diverse populations. Methodological challenges that hinder progress in controlled research for anorexia nervosa are explained.

CONCLUSIONS

The review highlights evidence-based and promising treatment modalities for anorexia nervosa and presents a triangulated analysis including controlled research, practice guidelines, and emerging treatments to inform and support clinical decision making.

Treating severe and enduring anorexia nervosa: a randomized controlled trial

BACKGROUND

There are no evidence-based treatments for severe and enduring anorexia nervosa (SE-AN). This study evaluated the relative efficacy of cognitive behavioral therapy (CBT-AN) and specialist supportive clinical management (SSCM) for adults with SE-AN.

METHOD

Sixty-three participants with a diagnosis of AN, who had at least a 7-year illness history, were treated in a multi-site randomized controlled trial (RCT). During 30 out-patient visits spread over 8 months, they received either CBT-AN or SSCM, both modified for SE-AN. Participants were assessed at baseline, end of treatment (EOT), and at 6- and 12-month post-treatment follow-ups. The main outcome measures were quality of life, mood disorder symptoms and social adjustment. Weight, eating disorder (ED) psychopathology, motivation for change and health-care burden were secondary outcomes.

RESULTS

Thirty-one participants were randomized to CBT-AN and 32 to SSCM with a retention rate of 85% achieved at the end of the study. At EOT and follow-up, both groups showed significant improvement. There were no differences between treatment groups at EOT. At the 6-month follow-up, CBT-AN participants had higher scores on the Weissman Social Adjustment Scale (WSAS; p = 0.038) and at 12 months they had lower Eating Disorder Examination (EDE) global scores (p = 0.004) and higher readiness for recovery (p = 0.013) compared to SSCM.

CONCLUSIONS

Patients with SE-AN can make meaningful improvements with both therapies. Both treatments were acceptable and high retention rates at follow-up were achieved. Between-group differences at follow-up were consistent with the nature of the treatments given.

Therapeutic alliance in two treatments for adults with severe and enduring anorexia nervosa

OBJECTIVE

The aim of this study was to investigate the strength and role of therapeutic alliance in a trial comparing Cognitive Behavioral Therapy for anorexia nervosa (CBT-AN) and Specialist Supportive Clinical Management for the treatment of severe and enduring AN (SE-AN).

METHOD

Participants were 63 adult females with SE-AN presenting to an outpatient, multisite randomized controlled trial conducted at two clinical sites. Participants completed measures assessing their perception of the quality of the therapeutic relationship, eating disorder (ED) symptomatology, and depressive symptomatology.

RESULTS

Beyond the effect of early treatment change and treatment assignment, early therapeutic alliance was a significant predictor of Restraint and Shape Concern at follow-up (ps < .02). Late therapeutic alliance was a significant predictor of weight change, depressive symptomatology, and ED symptomatology at end of treatment and follow-up (ps < .008), with the exception of Shape Concern at follow-up (p = .07).

DISCUSSION

The results suggest that therapeutic alliance can be effectively established in the treatment of SE-AN and may be relevant for treatment response, particularly in late treatment, on some aspects of ED and depressive symptomatology.

How do people achieve and remain at a comfortable weight?: an interpretative phenomenological analysis

This study aimed to examine how people change in order to achieve and maintain a personally comfortable weight and what changes for them as they change. Six students who changed to achieve and maintain a personally comfortable weight for a minimum of 1 year were recruited. Semi-structured interviews explored participants’ experiences of what changed and how they changed. The interviews were analysed using interpretative phenomenological analysis. Two superordinate themes emerged. The first was ‘awareness’ which contained the subthemes: unaware self, revelation, and conscious monitoring and maintenance of awareness. The second was ‘goals and needs’ which contained the subthemes: social- vs. self-acceptance, removing negative emotions, weight control vs. other life goals, and ideal vs. perceived health and appearance. The findings are discussed in relation to the existing literature on the development of eating problems, involving social acceptance, self-esteem, coping with negative moods, and weight control. Perceptual Control Theory was used to provide an explanation for how these participants changed and maintained their change.

Assessment of quality of life in people with severe and enduring anorexia nervosa: a comparison of generic and specific instruments

BACKGROUND

Criticisms that generic measures of health-related quality of life (HRQoL) are not sensitive to impairment in anorexia nervosa (AN) has spurred the development of disease-specific measures. This study aimed to compare the psychometric properties of a generic to a disease-specific measure of HRQoL.

METHODS

63 participants with AN completed measures of a generic HRQoL (SF-12), disease-specific HRQoL (Eating Disorders Quality of Life Questionnaire; EDQOL), functional impairment (days out of role; DOR; Work and Social Adjustment Scale; WSAS), and eating disorder severity (Eating Disorder Examination; EDE) at baseline, post-treatment, and 6- and 12-months follow-up. Cronbach's α was computed for the SF-12 and EDQOL (internal consistency). Correlations were assessed between SF-12/EDQOL scores and DOR, WSAS, and EDE scores (convergence validity). Three sets of three multiple linear regressions were performed using SF-12 and EDQOL scores as predictors and change in DOR, WSAS, and EDE global scores from baseline to (i) post-treatment, (ii) 6-month follow-up, (iii) and 12-month follow-up as dependent variables (predictive validity and sensitivity).

RESULTS

The EDQOL displayed stronger internal consistency (α = 0.92) than the SF-12 (α = 0.80). The SF-12 converged more strongly with DOR and the WSAS (r(p) = -0.31 to -0.63 vs. 0.06 to 0.70), while the EDQOL converged more strongly with the EDE (r(p) = -0.01 to 0.48 vs. -0.01 to -0.37). The SF-12 demonstrated stronger predictive validity (β = -0.55 to 0.29) and sensitivity to changes in ED severity (β = -0.47 to 0.32).

CONCLUSIONS

The SF-12 is a valid and sensitive measure of HRQoL impairment in patients with AN. While the SF-12 may be preferred in research comparing EDs to other populations, and in research and practice as an indicator of functional impairment; the EDQOL may be preferred by clinicians and researchers interested in HRQoL impairment specifically associated with an ED and as an additional indicator of ED severity.

Drop-out and treatment outcome of outpatient cognitive-behavioral therapy for anorexia nervosa and bulimia nervosa

In the present study, drop-out-analyses were carried out for a manual-based cognitive-behavioral therapy for 104 females with anorexia nervosa (AN) and bulimia nervosa (BN), in the service setting of a university outpatient clinic (naturalistic setting). A total of 22.9% of patients with AN terminated therapy prematurely (drop-outs), compared to 40.6% of patients with BN. Group differences between drop-outs and completers show that the group of drop-outs with BN had higher values in the depression score at the start of therapy and was almost two times more likely to have a comorbid disorder (odds ratio 1.69), whereas drop-outs with AN had higher values in the outcome-scale drive for thinness and the odds ratio for being employed or living in a partnership was slightly lower. Completers and drop-outs did not differ significantly within groups in regard to age, body mass index at the start and end of therapy, or the number of comorbid disorders. On the whole, the therapy effect in the group of drop-outs was relatively moderate. For patients with AN, even higher therapy effects were observed among the drop-outs than among the completers. These data suggest that moderate therapy effects and responses can be achieved even among the drop-outs.

Inpatient cognitive behaviour therapy for anorexia nervosa: a randomized controlled trial

BACKGROUND

The aim of this study was to compare the immediate and longer-term effects of two cognitive behaviour therapy programmes for hospitalized patients with anorexia nervosa, one focused exclusively on the patients' eating disorder features and the other focused also on mood intolerance, clinical perfectionism, core low self-esteem or interpersonal difficulties. Both programmes were derived from enhanced cognitive behaviour therapy (CBT-E) for eating disorders.

METHODS

Eighty consecutive patients with severe anorexia nervosa were randomized to the two inpatient CBT-E programmes, both of which involved 20 weeks of treatment (13 weeks as an inpatient and 7 as a day patient). The patients were then followed up over 12 months. The assessments were made blind to treatment condition.

RESULTS

Eighty-one percent of the eligible patients accepted inpatient CBT-E, of whom 90% completed the 20 weeks of treatment. The patients in both programmes showed significant improvements in weight, eating disorder and general psychopathology. Deterioration after discharge did occur but it was not marked and it was restricted to the first 6 months. There were no statistically significant differences between the effects of the two programmes.

CONCLUSIONS

These findings suggest that both versions of inpatient CBT-E are well accepted by these severely ill patients and might be a viable and promising treatment for severe anorexia nervosa. There appears to be no benefit from using the more complex form of the treatment.

Internet-based relapse prevention for anorexia nervosa: nine- month follow-up

BACKGROUND

To study the longer term effects of an internet-based CBT intervention for relapse prevention (RP) in anorexia nervosa.

METHODS

210 women randomized to the RP intervention group (full and partial completers) or the control group were assessed for eating and general psychopathology. Multiple regression analysis identified predictors of favorable course concerning Body Mass Index (BMI). Logistic regression analysis identified predictors of adherence to the RP program.

RESULTS

Most variables assessed showed more improvement for the RP than for the control group. However, only some scales reached statistical significance (bulimic behavior and menstrual function, assessed by expert interviewers blind to treatment condition). Very good results (BMI) were seen for the subgroup of "full completers" who participated in all nine monthly RP internet-based intervention sessions. "Partial completers" and controls (the latter non-significantly) underwent more weeks of inpatient treatment during the study period than "full completers", indicating better health and less need for additional treatment among the "full completers". Main long-term predictors for favorable course were adherence to RP, more spontaneity, and more ineffectiveness. Main predictors of good adherence to RP were remission from lifetime mood and lifetime anxiety disorder, a shorter duration of eating disorder, and additional inpatient treatment during RP.

CONCLUSIONS

Considering the high chronicity of AN, internet-based relapse prevention following intensive treatment appears to be promising.

Why it is time to develop the use of cognitive event-related potentials in the treatment of psychiatric diseases

The relapse rate for many psychiatric disorders is staggeringly high, indicating that treatment methods combining psychotherapy with neuropharmacological interventions are not entirely effective. Therefore, in psychiatry, there is a current push to develop alternatives to psychotherapy and medication-based approaches. Cognitive deficits have gained considerable importance in the field as critical features of mental illness, and it is now believed that they might represent valid therapeutic targets. Indeed, an increase in cognitive skills has been shown to have a long-lasting, positive impact on the patients' quality of life and their clinical symptoms. We hereby present four principal arguments supporting the use of event-related potentials (ERP) that are derived from electroencephalography, which allow the identification of specific neurocognitive deficiencies in patients. These arguments could assist psychiatrists in the development of individualized, targeted therapy, as well as a follow-up and rehabilitation plan specific to each patient's deficit. Furthermore, they can be used as a tool to assess the possible benefits of combination therapy, consisting of medication, psychotherapy, and "ERP-oriented cognitive rehabilitation". Using this strategy, specific cognitive interventions could be planned based on each patient's needs, for an "individualized" or "personalized" therapy, which may have the potential to reduce relapse rates for many psychiatric disorders. The implementation of such a combined approach would require intense collaboration between psychiatry departments, clinical neurophysiology laboratories, and neuropsychological rehabilitation centers.

Treatment for severe and enduring anorexia nervosa: a review

OBJECTIVE

Many patients with anorexia nervosa develop an intractable and debilitating illness course. Our aims were to (i) conduct a systematic review of randomised controlled trials (RCTs) of treatment for chronic anorexia nervosa participants, and (ii) identify research informing novel therapeutic approaches for this group.

METHODS

Systematic search (SCOPUS plus previous reviews date 2011) of literature for (i) RCTs of treatment that included anorexia nervosa participants with a mean duration of illness of at least 3 years, (ii) studies reporting new treatments addressing factors associated with chronicity.

RESULTS

Evidence of efficacy for treatment approaches in severe and enduring anorexia nervosa is limited. Only one unpublished RCT designed to test a specific psychological approach for these patients was identified. There is a probable advantage for specialist psychotherapy over treatment as usual, and a promising study of relapse prevention with cognitive behaviour therapy (CBT) for anorexia nervosa (CBT-AN). Open trials have, however, reported developments in psychological therapies that warrant further specific evaluation. These include forms of CBT modified for anorexia nervosa, cognitive remediation therapy with emotion skills training, the Maudsley Model for Treatment of Adults with Anorexia Nervosa, the Community Outreach Partnership Program, Specialist Supportive Clinical Management and the approach of Strober with its emphasis on therapeutic alliance and flexible goals.

CONCLUSIONS

Treatment trials need to move beyond targeting core eating disorder pathology (primarily weight restoration) and examine efficacy and effectiveness in minimising harm and reducing personal and social costs of chronic illness. There is also a need to develop better definitions of chronicity, with or without treatment 'resistance' specifiers.

Pharmacologic and psychotherapeutic treatment of anorexia nervosa

This article will review the treatment research literature on patients with anorexia nervosa. Perhaps somewhat surprisingly, the controlled treatment literature on this disorder is fairly limited. This is attributable to several factors, including the fact that many patients with anorexia nervosa are difficult to engage in treatment and unwilling to participate in randomized trials, and that many of these patients are so critically ill that they require a multiplicity of interventions and long-term therapy, creating design problems for randomized trials. Nonetheless, the extant literature will be reviewed, including pharmacologic and psychotherapeutic interventions in adolescents and adults. One point that needs to be addressed at the outset is the proper venue for the treatment of anorexia nervosa. Many patients, particularly those very low in weight, require in-patient and/or partial hospital treatment as the initial intervention. Although third-party payers are increasingly reluctant to pay for such interventions, they remain the treatments of choice for many anorectic patients. Another issue concerns acute treatment, focusing on weight gain, versus relapse prevention, focusing on weight maintenance and further work on anorectic psychopathology. Different studies have focused on different areas.

Nonspecific predictors of weight gain in the early stages of outpatient cognitive behavioral therapy for adults with anorexia nervosa: Replication and extension

OBJECTIVE

This study extends previous work, examining psychological factors that influence the level of weight gain across the first 20 sessions of cognitive behavioral therapy (CBT) for anorexia nervosa.

METHOD

Thirty-two patients with anorexia nervosa (mean body mass index (BMI) = 16.0; SD = 1.11) completed measures of eating attitudes and comorbid axis 1 pathology at the outset of CBT, and their weight gain was measured at the 6th and 20th sessions of the therapy.

RESULTS

Unhealthy eating attitudes at the start of therapy were associated with slower weight gain across the first 20 sessions of CBT. In contrast, higher levels of pretreatment axis 1 pathology were associated with slower weight gain only after the 6th session. The axis 1 features that moderated weight gain over 20 sessions of CBT were broader than those that had previously been shown to predict weight gain over the first 10 CBT sessions.

DISCUSSION

During CBT for anorexia nervosa, weight gain might be enhanced by addressing a range of aspects of axis 1 pathology (e.g., depression, hostility, and features of anxiety). However, the approach is likely to be less important at first than directly addressing eating pathology and overvalued ideas about eating, shape, and weight.

Longstanding underweight eating disorder: associated features and treatment outcome

The clinical features and the response to inpatient cognitive-behavior treatment (I-CBT) of underweight individuals with either longstanding or more recent-onset eating disorder have rarely been compared. We compared the psychopathological profile and the response to I-CBT of 37 female patients with longstanding eating disorder (≥10 years, L-ED) and 58 with shorter disease duration. Individuals with L-ED had higher age, baseline BMI, higher frequency of self-induced vomiting, laxative and diuretic misuse, but not different personality traits at baseline and not different psychopathological changes, outcome, and dropout rates in response to I-CBT. This study provides preliminary evidence that I-CBT may be useful to treat L-ED and improve their eating disorder psychopathology.

The role of ghrelin, salivary secretions, and dental care in eating disorders

Eating disorders, including anorexia and bulimia nervosa, are potentially life-threatening syndromes characterized by severe disturbances in eating behavior. An effective treatment strategy for these conditions remains to be established, as patients with eating disorders tend to suffer from multiple relapses. Because ghrelin was originally discovered in the stomach mucosa, it has been widely studied over the past decade in an effort to uncover its potential roles; these studies have shed light on the mechanism by which ghrelin regulates food intake. Thus, studying ghrelin in the context of eating disorders could improve our understanding of the pathogenesis of eating disorders, possibly resulting in a promising new pharmacological treatment strategy for these patients. In addition, early detection and treatment of eating disorders are critical for ensuring recovery of young patients. Oral symptoms, including mucosal, dental, and saliva abnormalities, are typically observed in the early stages of eating disorders. Although oral care is not directly related to the treatment of eating disorders, knowledge of the oral manifestations of eating disorder patients may aid in early detection, resulting in earlier treatment; thus, oral care might contribute to overall patient management and prognosis. Moreover, ghrelin has also been found in saliva, which may be responsible for oral hygiene and digestion-related functions. This review discusses the pharmacological potential of ghrelin in regulating food-intake and the role of saliva and oral care in young patients with eating disorders.