The dearth of psychological treatment studies for anorexia nervosa

A scoping review of non-specific predictors, moderators, and mediators of family-based treatment for adolescent anorexia and bulimia nervosa: a summary of the current research findings

PURPOSE

This scoping review presents an up-to-date synthesis of the current evidence base for non-specific predictors, moderators, and mediators of family-based treatment (FBT) for adolescent anorexia and bulimia nervosa.

METHODS

We identify ways in which end-of-treatment outcomes have been shown to differ based upon baseline clinical features and person-specific factors and explore psychological mechanisms that may explain differences in treatment response. We draw from this evidence base to outline recommendations for clinical practice, as well as directions for future clinical eating disorder research.

RESULTS

Noted findings from review include that early response in weight gain and parental criticism may be particularly influential in treatment for anorexia nervosa. Further, for adolescents with either anorexia or bulimia nervosa, eating-related obsessionality may be a key intervention target to improve outcomes.

CONCLUSION

In addition to highlighting a need for attention to specific patient- and caregiver-level factors that impact treatment response, recommendations for research and clinical practice include testing whether certain targeted treatments (e.g., exposure-based approaches) may be suitable within the context of FBT for eating disorders.

LEVEL OF EVIDENCE

Level I: Evidence obtained from: at least one properly designed randomized controlled trials; experimental studies.

Family-based Treatment of Eating Disorders: A Narrative Review

Eating disorders (EDs) are serious psychiatric illnesses that typically develop during adolescence or young adulthood, indicating that individuals with EDs may benefit from early intervention. Family-based treatment is the leading treatment of youth with anorexia nervosa, with increasing evidence of its efficacy for youth with bulimia nervosa. This review describes the role of family engagement within family-based treatment of EDs, followed by a summary of current empirically supported, family-based ED interventions. It concludes with discussion of the ways in which family interventions are expanding and adapting to improve the breadth and scope of ED treatment in adolescence and young adulthood.

Family therapy approaches for anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is characterised by a failure to maintain a normal body weight due to a paucity of nutrition, an intense fear of gaining weight or behaviour that prevents the individual from gaining weight, or both. The long-term prognosis is often poor, with severe developmental, medical and psychosocial complications, high rates of relapse and mortality. 'Family therapy approaches' indicate a range of approaches, derived from different theories, that involve the family in treatment. We have included therapies developed on the basis of dominant family systems theories, approaches that are based on or broadly similar to the family-based therapy derived from the Maudsley model, approaches that incorporate a focus on cognitive restructuring, as well as approaches that involve the family without articulation of a theoretical approach.This is an update of a Cochrane Review first published in 2010.

OBJECTIVES

To evaluate the efficacy of family therapy approaches compared with standard treatment and other treatments for AN.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) and PsycINFO (OVID) (all years to April 2016). We ran additional searches directly on Cochrane Central Register for Controlled Trials (CENTRAL), MEDLINE, Ovid Embase, and PsycINFO (to 2008 and 2016 to 2018). We searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov, together with four theses databases (all years to 2018). We checked the reference lists of all included studies and relevant systematic reviews. We have included in the analyses only studies from searches conducted to April 2016.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of family therapy approaches compared to any other intervention or other types of family therapy approaches were eligible for inclusion. We included participants of any age or gender with a primary clinical diagnosis of anorexia nervosa.

DATA COLLECTION AND ANALYSIS

Four review authors selected the studies, assessed quality and extracted data. We used a random-effects meta-analysis. We used the risk ratio (with a 95% confidence interval) to summarise dichotomous outcomes and both the standardised mean difference and the mean difference to summarise continuous measures.

MAIN RESULTS

We included 25 trials in this version of the review (13 from the original 2010 review and 12 newly-included studies). Sixteen trials were of adolescents, eight trials of adults (seven of these in young adults aged up to 26 years) and one trial included three age groups: one adolescent, one young adult and one adult. Most investigated family-based therapy or variants. Reporting of trial conduct was generally inadequate, so that in a large number of studies we rated the risk of bias as unclear for many of the domains. Selective reporting bias was particularly problematic, with 68% of studies rated at high risk of bias in this area, followed by incomplete outcome data, with 44% of studies rated at high risk of bias in this area. For the main outcome measure of remission there was some low-quality evidence (from only two studies, 81 participants) suggesting that family therapy approaches might offer some advantage over treatment as usual on rates of remission, post intervention (risk ratio (RR) 3.50, 95% confidence interval (CI) 1.49 to 8.23; I² = 0%). However, at follow-up, low-quality evidence from only one study suggested this effect was not maintained. There was very low-quality evidence from only one trial, which means it is difficult to determine whether family therapy approaches offer any advantage over educational interventions for remission (RR 9.00, 95% CI 0.53 to 153.79; 1 study, N = 30). Similarly, there was very low-quality evidence from only five trials for remission post-intervention, again meaning that it is difficult to determine whether there is any advantage of family therapy approaches over psychological interventions (RR 1.22, 95% CI 0.89 to 1.67; participants = 252; studies = 5; I² = 37%) and at long-term follow-up (RR 1.08, 95% CI 0.91 to 1.28; participants = 200; studies = 4 with 1 of these contributing 3 pairwise comparisons for different age groups; I² = 0%). There was no indication that the age group had any impact on the overall treatment effect; however, it should be noted that there were very few trials undertaken in adults, with the age range of adult studies included in this analysis from 20 to 27. There was some evidence of a small effect favouring family based therapy compared with other psychological interventions in terms of weight gain post-intervention (standardised mean difference (SMD) 0.32, 95% CI 0.01 to 0.63; participants = 210; studies = 4 with 1 of these contributing 3 pairwise comparisons for different age groups; I² = 11%) . Overall, there was insufficient evidence to determine whether there were any differences between groups across all comparisons for most of the secondary outcomes (weight, eating disorder psychopathology, dropouts, relapse, or family functioning measures), either at post-intervention or at follow-up.

AUTHORS' CONCLUSIONS

There is a limited amount of low-quality evidence to suggest that family therapy approaches may be effective compared to treatment as usual in the short term. This finding is based on two trials that included only a small number of participants, and both had issues about potential bias. There is insufficient evidence to determine whether there is an advantage of family therapy approaches in people of any age compared to educational interventions (one study, very low quality) or other psychological therapies (five studies, very low quality). Most studies contributing to this finding were undertaken in adolescents and youth. There are clear potential impacts on how family therapy approaches might be delivered to different age groups and further work is required to understand what the resulting effects on treatment efficacy might be. There is insufficient evidence to determine whether one type of family therapy approach is more effective than another. The field would benefit from further large, well-conducted trials.

Therapeutic Alliance and Anorexia Nervosa Treatment Outcomes: Experiences of Young People and Their Families

Treatments for anorexia nervosa provided early in the onset of the illness lead to better outcomes. Despite the treatment approach used, the therapeutic alliance may be instrumental in successful outcomes. The aim of this study was to explore the young people and their families' experiences of the illness, and their access to and satisfaction with the services received. Of particular interest was their view of the working alliance with their therapist/s. Participants were interviewed by telephone using a semi-structured questionnaire. Family based treatment or the Maudsley was found superior to other treatments with regard to physical markers of recovery, satisfaction with the services and therapy received, as well as the strength of the therapeutic alliance. All the interviewees stressed the need for more research, education, accessibility and flexibility of services and increased support for both the young people and their families.

Family therapy approaches for anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is characterised by a failure to maintain a normal body weight due to a paucity of nutrition, an intense fear of gaining weight or behaviour that prevents the individual from gaining weight, or both. The long-term prognosis is often poor, with severe developmental, medical and psychosocial complications, high rates of relapse and mortality. 'Family therapy approaches' indicate a range of approaches, derived from different theories, that involve the family in treatment. We have included therapies developed on the basis of dominant family systems theories, approaches that are based on or broadly similar to the family-based therapy derived from the Maudsley model, approaches that incorporate a focus on cognitive restructuring, as well as approaches that involve the family without articulation of a theoretical approach.This is an update of a Cochrane Review first published in 2010.

OBJECTIVES

To evaluate the efficacy of family therapy approaches compared with standard treatment and other treatments for AN.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) and PsycINFO (OVID) (all years to April 2016). We ran additional searches directly on Cochrane Central Register for Controlled Trials (CENTRAL), MEDLINE, Ovid Embase, and PsycINFO (to 2008 and 2016 to 2018). We searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov, together with four theses databases (all years to 2018). We checked the reference lists of all included studies and relevant systematic reviews. We have included in the analyses only studies from searches conducted to April 2016.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of family therapy approaches compared to any other intervention or other types of family therapy approaches were eligible for inclusion. We included participants of any age or gender with a primary clinical diagnosis of anorexia nervosa.

DATA COLLECTION AND ANALYSIS

Four review authors selected the studies, assessed quality and extracted data. We used a random-effects meta-analysis. We used the risk ratio (with a 95% confidence interval) to summarise dichotomous outcomes and both the standardised mean difference and the mean difference to summarise continuous measures.

MAIN RESULTS

We included 25 trials in this version of the review (13 from the original 2010 review and 12 newly-included studies). Sixteen trials were of adolescents, eight trials of adults (seven of these in young adults aged up to 26 years) and one trial included three age groups: one adolescent, one young adult and one adult. Most investigated family-based therapy or variants. Reporting of trial conduct was generally inadequate, so that in a large number of studies we rated the risk of bias as unclear for many of the domains. Selective reporting bias was particularly problematic, with 68% of studies rated at high risk of bias in this area, followed by incomplete outcome data, with 44% of studies rated at high risk of bias in this area. For the main outcome measure of remission there was some low-quality evidence (from only two studies, 81 participants) suggesting that family therapy approaches might offer some advantage over treatment as usual on rates of remission, post intervention (risk ratio (RR) 3.50, 95% confidence interval (CI) 1.49 to 8.23; I2 = 0%). However, at follow-up, low-quality evidence from only one study suggested this effect was not maintained. There was very low-quality evidence from only one trial, which means it is difficult to determine whether family therapy approaches offer any advantage over educational interventions for remission (RR 9.00, 95% CI 0.53 to 153.79; 1 study, N = 30). Similarly, there was very low-quality evidence from only five trials for remission post-intervention, again meaning that it is difficult to determine whether there is any advantage of family therapy approaches over psychological interventions (RR 1.22, 95% CI 0.89 to 1.67; participants = 252; studies = 5; I2 = 37%) and at long-term follow-up (RR 1.08, 95% CI 0.91 to 1.28; participants = 200; studies = 4 with 1 of these contributing 3 pairwise comparisons for different age groups; I2 = 0%). There was no indication that the age group had any impact on the overall treatment effect; however, it should be noted that there were very few trials undertaken in adults, with the age range of adult studies included in this analysis from 20 to 27. There was some evidence of a small effect favouring family based therapy compared with other psychological interventions in terms of weight gain post-intervention (standardised mean difference (SMD) 0.32, 95% CI 0.01 to 0.63; participants = 210; studies = 4 with 1 of these contributing 3 pairwise comparisons for different age groups; I2 = 11%) . Overall, there was insufficient evidence to determine whether there were any differences between groups across all comparisons for most of the secondary outcomes (weight, eating disorder psychopathology, dropouts, relapse, or family functioning measures), either at post-intervention or at follow-up.

AUTHORS' CONCLUSIONS

There is a limited amount of low-quality evidence to suggest that family therapy approaches may be effective compared to treatment as usual in the short term. This finding is based on two trials that included only a small number of participants, and both had issues about potential bias. There is insufficient evidence to determine whether there is an advantage of family therapy approaches in people of any age compared to educational interventions (one study, very low quality) or psychological therapies (five studies, very low quality). Most studies contributing to this finding were undertaken in adolescents and youth. There are clear potential impacts on how family therapy approaches might be delivered to different age groups and further work is required to understand what the resulting effects on treatment efficacy might be. There is insufficient evidence to determine whether one type of family therapy approach is more effective than another. The field would benefit from further large, well-conducted trials.

Early adolescents' body dysmorphic symptoms as compensatory responses to parental appearance messages and appearance-based rejection sensitivity

Body dysmorphic disorder (BDD) is marked by high distress and behavioral and functional impairments due to preoccupation with perceived appearance anomalies. Our aim was to examine parental correlates of offspring's symptoms characteristic of BDD, testing both direct associations and indirect associations via appearance-based rejection sensitivity (appearance-RS). Surveys were completed by 302 Australian adolescents (9-14 years) and their parents. Findings indicated parents' weight and appearance teasing and child-report (but not parent-report) of parental negative attitudes about weight and appearance were uniquely associated with offspring's heightened BDD-like symptoms, and associations were partially indirect via adolescents' appearance-RS. Findings support theory that identifies parents as socializers of children's appearance concerns, and show that BDD-like symptoms may be partly elevated because of the mediating role of appearance-RS. We propose that BDD symptoms could partly emerge as compensatory responses to parents' appearance messages, and the associated bias to expect and perceive rejection based on one's appearance.

Favorable effects of clearly defined interventions by parents at the start of treatment of adolescents with restrictive eating disorders

OBJECTIVE

To study the effect of clearly defined and decisive parental interventions at the start of treatment of restrictive eating disorders (ED) in adolescents.

METHOD

Forty-seven adolescents with ED (anorexia nervosa = 6, bulimia nervosa = 1, EDNOS = 40) and their families participated. Parents were advised to (1) keep the adolescent home from school, (2) eat all meals together with the adolescent, (3) prevent any form of exercise, and (4) prevent vomiting during the first week of treatment. Weight change was followed up to three months and EDE-Q administered at start of treatment and at three months.

RESULTS

Thirty (64%) of the families accomplished all four interventions during the first week of treatment. Their adolescents gained ∼ 1 kg of weight at one week, 2 kg at one month, and 4 kg at three months while adolescents in families who did not accomplish all four interventions gained only 1.4 kg up to three months. Scores on the EDE-Q decreased during treatment and in adolescents of families who accomplished all four interventions they were in the range of a reference population.

DISCUSSION

Decisive parental management of eating disturbed behaviors at the start of treatment of adolescents with ED promotes later clinical outcome. The finding supports the view that family based therapies are effective in adolescent ED. Results has to be followed up for evaluation of the long term effects of this type of intervention.

Listening in the dark: why we need stories of people living with severe and enduring anorexia nervosa

A bold step forward in our approach to Severe and Enduring Anorexia Nervosa invites new paradigms for research and practice. It provides an opportunity for us to explore fault lines, both in our communities of practice and the social structures that inform them. This paper serves to question the medical metaphors on which treatment has been based, in favour of alternative perspectives that resonate more clearly with the lived experience of those for whom it has failed. We invite the consideration of alternative metaphors, which can disrupt the notion of heroic patients (and therapists), mediate against acts of self-silencing and sensitising us to more radical acts of listening. Beyond the randomised trials and manuals it is time for us to listen to the realities of suffering, the minutiae of resistance and the life that can still be lived.

An open trial of Acceptance-based Separated Family Treatment (ASFT) for adolescents with anorexia nervosa

Family based-treatments have the most empirical support in the treatment of adolescent anorexia nervosa; yet, a significant percentage of adolescents and their families do not respond to manualized family based treatment (FBT). The aim of this open trial was to conduct a preliminary evaluation of an innovative family-based approach to the treatment of anorexia: Acceptance-based Separated Family Treatment (ASFT). Treatment was grounded in Acceptance and Commitment Therapy (ACT), delivered in a separated format, and included an ACT-informed skills program. Adolescents (ages 12-18) with anorexia or sub-threshold anorexia and their families received 20 treatment sessions over 24 weeks. Outcome indices included eating disorder symptomatology reported by the parent and adolescent, percentage of expected body weight achieved, and changes in psychological acceptance/avoidance. Half of the adolescents (48.0%) met criteria for full remission at the end of treatment, 29.8% met criteria for partial remission, and 21.3% did not improve. Overall, adolescents had a significant reduction in eating disorder symptoms and reached expected body weight. Treatment resulted in changes in psychological acceptance in the expected direction for both parents and adolescents. This open trial provides preliminary evidence for the feasibility, acceptability, and efficacy of ASFT for adolescents with anorexia. Directions for future research are discussed.

A pilot study of maudsley family therapy with group dialectical behavior therapy skills training in an intensive outpatient program for adolescent eating disorders

OBJECTIVE

The goal of this study was to provide pilot clinical data on the effectiveness of an intensive outpatient treatment model for adolescent eating disorders that combines Maudsley-based family therapy and group dialectical behavior therapy skills training.

METHOD

Measures of physical and psychological status were gathered upon admission, discharge, and at 3 follow-up intervals.

RESULTS

Adolescents who completed the program gained a significant amount of weight and experienced a significant decrease in eating disorder psychopathology. At the 1-year follow-up, 64% of adolescents were weight restored and menstruating normally. Measures of eating disorder psychopathology continued to improve up to a year after treatment.

CONCLUSIONS

This pilot, multimodal program warrants further investigation and may be an effective intermediate level of care treatment option for adolescent eating disorders.

Predictors of outcome at 1 year in adolescents with DSM-5 restrictive eating disorders: report of the national eating disorders quality improvement collaborative

PURPOSE

The National Eating Disorders Quality Improvement Collaborative evaluated data of patients with restrictive eating disorders to analyze demographics of diagnostic categories and predictors of weight restoration at 1 year.

METHODS

Fourteen Adolescent Medicine eating disorder programs participated in a retrospective review of 700 adolescents aged 9-21 years with three visits, with DSM-5 categories of restrictive eating disorders including anorexia nervosa (AN), atypical AN, and avoidant/restrictive food intake disorder (ARFID). Data including demographics, weight and height at intake and follow-up, treatment before intake, and treatment during the year of follow-up were analyzed.

RESULTS

At intake, 53.6% met criteria for AN, 33.9% for atypical AN, and 12.4% for ARFID. Adolescents with ARFID were more likely to be male, younger, and had a longer duration of illness before presentation. All sites had a positive change in mean percentage median body mass index (%MBMI) for their population at 1-year follow-up. Controlling for age, gender, duration of illness, diagnosis, and prior higher level of care, only %MBMI at intake was a significant predictor of weight recovery. In the model, there was a 12.7% change in %MBMI (interquartile range, 6.5-19.3). Type of treatment was not predictive, and there were no significant differences between programs in terms of weight restoration.

CONCLUSIONS

The National Eating Disorders Quality Improvement Collaborative provides a description of the patient population presenting to a national cross-section of 14 Adolescent Medicine eating disorder programs and categorized by DSM-5. Treatment modalities need to be further evaluated to assess for more global aspects of recovery.

Radically open-dialectical behavior therapy for adult anorexia nervosa: feasibility and outcomes from an inpatient program

BACKGROUND

Anorexia Nervosa (AN) is a highly life-threatening disorder that is extremely difficult to treat. There is evidence that family-based therapies are effective for adolescent AN, but no treatment has been proven to be clearly effective for adult AN. The methodological challenges associated with studying the disorder have resulted in recommendations that new treatments undergo preliminary testing prior to being evaluated in a randomized clinical trial. The aim of this study was to provide preliminary evidence on the effectiveness of a treatment program based on a novel adaptation of Dialectical Behavior Therapy (DBT) for adult Anorexia Nervosa (Radically Open-DBT; RO-DBT) that conceptualizes AN as a disorder of overcontrol.

METHODS

Forty-seven individuals diagnosed with Anorexia Nervosa-restrictive type (AN-R; mean admission body mass index = 14.43) received the adapted DBT inpatient program (mean length of treatment = 21.7 weeks).

RESULTS

Seventy-two percent completed the treatment program demonstrating substantial increases in body mass index (BMI; mean change in BMI = 3.57) corresponding to a large effect size (d = 1.91). Thirty-five percent of treatment completers were in full remission, and an additional 55% were in partial remission resulting in an overall response rate of 90%. These same individuals demonstrated significant and large improvements in eating-disorder related psychopathology symptoms (d = 1.17), eating disorder-related quality of life (d = 1.03), and reductions in psychological distress (d = 1.34).

CONCLUSIONS

RO-DBT was associated with significant improvements in weight gain, reductions in eating disorder symptoms, decreases in eating-disorder related psychopathology and increases in eating disorder-related quality of life in a severely underweight sample. These findings provide preliminary support for RO-DBT in treating AN-R suggesting the importance of further evaluation examining long-term outcomes using randomized controlled trial methodology.

An exploration of the perceptions and experiences of living with chronic anorexia nervosa while an inpatient on an Eating Disorders Unit: An Interpretative Phenomenological Analysis (IPA) study

Chronic anorexia nervosa (cAN) is a challenging presentation for the clinician. Motivation to recover is low, and outcomes are often poor. Within this study. six participants, currently in treatment, were interviewed. These interview transcripts were analysed using Interpretative Phenomenological Analysis. The results highlighted five superordinate themes resulted from the analysis and these referred to the following points: (1) ‘making sense of AN’, (2) ‘experience of treatment/treatment’, (3) ‘interpersonal relationships’, (4) ‘battling with anorexia’ and (5) ‘staff pessimism in the treatment of cAN’. These results highlighted how the self is entwined with anorexia nervosa and thus making it incredibly difficult to perceive a life without cAN.

Effectiveness of a multimodal inpatient treatment for adolescents with anorexia nervosa in comparison with adults: an analysis of a specialized inpatient setting : treatment of adolescent and adult anorexics

OBJECTIVE

There is evidence for an increased prevalence and an earlier onset of anorexia nervosa (AN) in adolescents. Early specialized treatment may improve prognosis and decrease the risk of a chronic course. The current study evaluates the effectiveness of a multimodal inpatient treatment for adolescent AN patients treated in a highly specialized eating disorder unit for adults.

METHOD

177 adolescents and 1,064 adult patients were included. The evaluation focused on eating behavior, depressive symptoms and general psychopathology.

RESULTS

All measured variables decreased significantly in both groups during inpatient treatment. No differences were found concerning weight gain, improvement of global eating disorder symptomatology as well as depressive symptoms. However, adults showed a higher psychological distress and in this regard also a greater improvement.

CONCLUSION

Results indicate that treating adolescent AN patients in a highly specialized eating disorder unit for adults can be an effective treatment setting for these patients.

The use of effective treatments: the case of an adolescent girl with anorexia nervosa in the context of a conversion disorder

The use of empirically supported treatment (EST) has been shown to enhance treatment outcome. The purpose of this case study was to suggest that ESTs further encourage effective reconceptualisation and the ongoing delivery of effective treatment, especially in the case of complex or atypical presentations or response to treatment. This report describes the case of an adolescent girl who underwent Maudsley family-based treatment for anorexia nervosa (AN) for a period of 12 months. Atypical response lead to an understanding of her presentation as representing a primary conversion disorder, within which AN symptoms were conceptualised as another somatic conversion of emotional distress. The report details her clinical presentation and management over the course of her illness. The case offers an important opportunity to explore the central role of the use of ESTs in guiding effective treatment delivery.

Transdiagnostic Theory and Application of Family-Based Treatment for Youth with Eating Disorders

This paper describes the transdiagnostic theory and application of family-based treatment (FBT) for children and adolescents with eating disorders. We review the fundamentals of FBT, a transdiagnostic theoretical model of FBT and the literature supporting its clinical application, adaptations across developmental stages and the diagnostic spectrum of eating disorders, and the strengths and challenges of this approach, including its suitability for youth. Finally, we report a case study of an adolescent female with eating disorder not otherwise specified (EDNOS) for whom FBT was effective. We conclude that FBT is a promising outpatient treatment for anorexia nervosa, bulimia nervosa, and their EDNOS variants. The transdiagnostic model of FBT posits that while the etiology of an eating disorder is unknown, the pathology affects the family and home environment in ways that inadvertently allow for symptom maintenance and progression. FBT directly targets and resolves family level variables, including secrecy, blame, internalization of illness, and extreme active or passive parental responses to the eating disorder. Future research will test these mechanisms, which are currently theoretical.

Physiologic estrogen replacement increases bone density in adolescent girls with anorexia nervosa

Anorexia nervosa (AN) is prevalent in adolescents and is associated with decreased bone mineral accrual at a time critical for optimizing bone mass. Low BMD in AN is a consequence of nutritional and hormonal alterations, including hypogonadism and low estradiol levels. Effective therapeutic strategies to improve BMD in adolescents with AN have not been identified. Specifically, high estrogen doses given as an oral contraceptive do not improve BMD. The impact of physiologic estrogen doses that mimic puberty on BMD has not been examined. We enrolled 110 girls with AN and 40 normal-weight controls 12 to 18 years of age of similar maturity. Subjects were studied for 18 months. Mature girls with AN (bone age [BA] ≥15 years, n = 96) were randomized to 100 µg of 17β-estradiol (with cyclic progesterone) or placebo transdermally for 18 months. Immature girls with AN (BA < 15 years, n = 14) were randomized to incremental low-dose oral ethinyl-estradiol (3.75 µg daily from 0 to 6 months, 7.5 µg from 6 to 12 months, 11.25 µg from 12 to 18 months) to mimic pubertal estrogen increases or placebo for 18 months. All BMD measures assessed by dual-energy X-ray absorptiometry (DXA) were lower in girls with AN than in control girls. At baseline, girls with AN randomized to estrogen (AN E + ) did not differ from those randomized to placebo (AN E-) for age, maturity, height, BMI, amenorrhea duration, and BMD parameters. Spine and hip BMD Z-scores increased over time in the AN E+ compared with the AN E- group, even after controlling for baseline age and weight. It is concluded that physiologic estradiol replacement increases spine and hip BMD in girls with AN.

The effectiveness of a day program for the treatment of adolescent anorexia nervosa

OBJECTIVE

The risks of anorexia nervosa (AN) are well established. Despite its severity, little certainty exists for practitioners, with ethical and financial limitations yielding few controlled studies establishing effective treatments. Thus, other methods of establishing treatment effectiveness are necessary. This study presents preliminary results of an open clinical trial of a day program for adolescents with AN.

METHOD

Participants were 26 anorectic females, 12-18 years, who completed the "Transition Program."

RESULTS

Significant change emerged on measures of weight gain, and behavioral and attitudinal measures of eating pathology. Large effect sizes were evident for weight gain at 6 month follow-up. Preliminary trends suggest that treatment gains on these and other measures of eating pathology were maintained at 6 month follow-up.

DISCUSSION

Preliminary results support day program treatment for adolescents with mild-moderately severe eating disorders. Present outcomes are discussed with respect to the dearth of efficacious treatment options for adolescents.

Eating disorder symptom severity scale: a new clinician rated measure

This study describes the development and validation of the clinician-rated Eating Disorder Symptom Severity Scale (EDS(3)), created to address a gap in measurement options for youth with eating disorders. The EDS(3) is modeled on the Childhood Severity and Acuity of Psychiatric Illness Scales (Lyons, J. S, 1998). Factor analysis revealed a 5-factor solution and accounted for 78% of the variance, and internal consistency within the subscales was good (Cronbach alphas: 0.69 to 0.93). The EDS(3) is a valid and reliable measure designed for clinicians to help assess the severity of a youth's eating disorder and to facilitate outcomes research.

Family therapy for anorexia nervosa

BACKGROUND

Anorexia Nervosa (AN) is characterised by distorted body image and deliberately maintained low body weight. The long term prognosis is often poor, with severe medical, developmental and psychosocial complications, high rates of relapse and mortality. Different variants of family therapy have been commonly used for intervention.

OBJECTIVES

To evaluate the efficacy of family therapy compared with standard treatment and other treatments.

SEARCH STRATEGY

The Cochrane Collaboration Depression, Anxiety and Neuroses Controlled Trials Register (CCDANCTR) was searched until August 2008; MEDLINE, PsycInfo and EMBASE and ClinicalTrials.gov were searched up to January 2008. A conference abstract book and included studies reference lists were searched. All lead authors of included studies were also contacted.

SELECTION CRITERIA

Randomised controlled trials (RCTS) of interventions described as 'family therapy' compared to any other intervention or other types of family therapy were eligible for inclusion. Patients of any age or gender with a primary clinical diagnosis of anorexia nervosa (AN) were included.

DATA COLLECTION AND ANALYSIS

Two review authors selected the studies, assessed quality and extracted data. We used a random effects meta-analysis. Relative risk was used to summarise dichotomous outcomes and both the standardised mean difference and mean difference to summarise continuous measures.

MAIN RESULTS

13 trials were included, the majority investigating family based therapy, or variants. Reporting of trial conduct was generally inadequate. The full extent of the risk of bias is unclear. There was some evidence (from two studies, 81 participants) to suggest that family therapy may be more effective than treatment as usual on rates of remission, in the short term (RR 3.83 95% CI 1.60 to 9.13). Based on one study (30 participants) there was no significant advantage for family therapy over educational interventions (RR 9.00 95% CI 0.53, 153.79) or over other psychological interventions (RR 1.13 95% CI 0.72 to 1.76) based on four studies (N=149).All other reported comparisons for relapse rates, cognitive distortion, weight measures and dropouts yielded non-significant results.

AUTHORS' CONCLUSIONS

There is some evidence to suggest that family therapy may be effective compared to treatment as usual in the short term. However, this is based on few trials that included only a small number of participants, all of which had issues regarding potential bias. There appears to be little advantage of family therapy over other psychological interventions. The field would benefit from a large, well-conducted trial.

How does overeaters anonymous help its members? A qualitative analysis

Overeaters Anonymous (OA) is a 12-step, self-help group for individuals who perceive themselves to have problems with compulsive overeating. Despite the popularity of OA and the frequent use of addictions-based treatments for eating disorders, little is known about how OA is helpful. The purpose of this qualitative study was to explore members' experiences with and perceptions of OA. We conducted three focus groups with self-selected members of OA (N = 20). We present three primary themes that emerged from the analysis of the focus groups' discussions, which emphasize why individuals entered OA, OA's 'tools', and how individuals perceived OA to 'work'. Overall, although participants agreed OA was helpful to them, there was no consensus regarding how OA 'works'.

The relationship between eating disorder not otherwise specified (EDNOS) and officially recognized eating disorders: meta-analysis and implications for DSM

Eating disorder not otherwise specified (EDNOS) is the most prevalent eating disorder (ED) diagnosis. In this meta-analysis, the authors aimed to inform Diagnostic and Statistical Manual of Mental Disorders revisions by comparing the psychopathology of EDNOS with that of the officially recognized EDs: anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). A comprehensive literature search identified 125 eligible studies (published and unpublished) appearing in the literature from 1987 to 2007. Random effects analyses indicated that whereas EDNOS did not differ significantly from AN and BED on eating pathology or general psychopathology, BN exhibited greater eating and general psychopathology than EDNOS. Moderator analyses indicated that EDNOS groups who met all diagnostic criteria for AN except for amenorrhea did not differ significantly from full syndrome cases. Similarly, EDNOS groups who met all criteria for BN or BED except for binge frequency did not differ significantly from full syndrome cases. Results suggest that EDNOS represents a set of disorders associated with substantial psychological and physiological morbidity. Although certain EDNOS subtypes could be incorporated into existing Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) categories, others-such as purging disorder and non-fat-phobic AN-may be best conceptualized as distinct syndromes. (PsycINFO Database Record (c) 2009 APA, all rights reserved).

Eighty-five per cent of what? Discrepancies in the weight cut-off for anorexia nervosa substantially affect the prevalence of underweight

BACKGROUND

DSM-IV cites <85% of expected body weight (EBW) as a guideline for the diagnosis of anorexia nervosa (AN) but does not require a specific method for calculating EBW. The purpose of the present study was to determine the degree to which weight cut-off calculations vary across studies, and to evaluate whether differential cut-offs lead to discrepancies in the prevalence of individuals who are eligible for the AN diagnosis.

METHOD

Two coders independently recorded the EBW calculation methods from 99 studies that either (a) compared individuals with AN to those with subclinical eating disorders or (b) conducted AN treatment trials. Each weight cut-off was applied to a nationally representative (n=12001) and treatment-seeking (n=189) sample to determine the impact of EBW calculation on the proportion who met the AN weight criterion.

RESULTS

Coders identified 10 different EBW methods, each of which produced different weight cut-offs for the diagnosis of AN. Although only 0.23% of the national sample met the lowest cut-off, this number increased 43-fold to 10.10% under the highest cut-off. Similarly, only 48.1% of treatment seekers met the lowest cut-off, whereas 89.4% met the highest.

CONCLUSIONS

There is considerable variance across studies in the determination of the AN weight cut-off. Discrepancies substantially affect the proportion of individuals who are eligible for diagnosis, treatment and insurance reimbursement. However, differences may not be fully appreciated because the ubiquitous citation of the 85% criterion creates a sense of false consensus.

Family interventions in adolescent anorexia nervosa

Although our understanding of the mechanisms of change in eating disorder treatment remain limited, the empiric evidence for the effectiveness of family therapy for adolescent Anorexia Nervosa is gaining strength. A history of family involvement in psychiatric care, current approaches to family intervention in eating disorders and evidence for their efficacy are reviewed.

Service users' feedback on cognitive training in the treatment of anorexia nervosa: a qualitative study

OBJECTIVE

There is little evidence to guide the treatment of anorexia nervosa (AN). Cognitive Remediation Therapy (CRT) may be helpful in reducing perfectionism and rigidity and preparing patients for involvement in later psychological interventions. The aim of this study was to examine service users' experiences of participating in CRT.

METHOD

Written feedback, following 10 CRT sessions, from 19 AN patients was analyzed using grounded theory approach.

RESULTS

Patients' feedback was generally positive. They found CRT refreshing and appreciated that it did not revolve around food. Patients found CRT helpful in reducing perfectionism and rigidity. The majority expressed how they were able to implement skills in their real life. Some changes were suggested, these included varying levels of difficulty and more guidance in implementing skills.

CONCLUSION

CRT is a promising component in the treatment of AN. Further research is being conducted to evaluate CRT.

Staging anorexia nervosa: conceptualizing illness severity

In recent years, there has been increasing attention to the conceptualization of anorexia nervosa (AN) and its diagnostic criteria. While varying levels of severity within the illness category of AN have long been appreciated, neither a precise definition of severity nor an empirical examination of severity in AN has been undertaken. The aim of this article is to review the current state of knowledge on illness severity and to propose a theoretical model for the definition and conceptualization of severity in AN. AN is associated with significant medical morbidity which is related to the 'severity' of presentation on such markers as body mass index, eating and purging behaviours. The development of a functional staging system, based on symptom severity, is indicated for reasons similar to those cited by the cancer lobby. Improving case management and making appropriate treatment recommendations have been the primary purpose of staging in other fields, and might also apply to AN. Such a standardized staging system could potentially ease communication between treatment settings, and increase the specificity and comparability of research findings in the field of AN.

The application of exposure therapy and D-cycloserine to the treatment of anorexia nervosa: a preliminary trial

OBJECTIVE

Novel approaches to the treatment of anorexia nervosa (AN) are needed. This preliminary study examined the utility and safety of an exposure therapy intervention and D-cycloserine (DCS) in a population of patients with AN.

METHOD

Eleven participants completed a series of 6 laboratory meals, including pre- and post-exposure test meals and four exposure sessions. Participants were randomly assigned to receive either DCS or placebo in double-blind fashion before each of the 4 exposure sessions. These results were compared to data from a previously studied group of patients who received treatment as usual.

RESULTS

Total caloric intake increased significantly from the baseline meal session to the post-test meal session in the patients who received the exposure therapy intervention. Caloric intake did not increase significantly in the comparison group.

CONCLUSION

These data suggest that an exposure therapy intervention specifically focused on meal consumption may be helpful in increasing intake of a test meal.

Open trial of family-based treatment for full and partial anorexia nervosa in adolescence: evidence of successful dissemination

OBJECTIVE

There is a paucity of evidence-based interventions for anorexia nervosa (AN). An innovative family-based treatment (FBT), developed at the Maudsley Hospital and recently put in manual form, has shown great promise for adolescents with AN. Unlike traditional treatment approaches, which promote sustained autonomy around food, FBT temporarily places the parents in charge of weight restoration. This aim of this open trial was to investigate the feasibility and effectiveness of delivering FBT at a site beyond the treatment's origin and manualization.

METHOD

Twenty adolescents (ages 12-17) with AN or subthreshold AN were treated with up to 1 year of FBT using the published treatment manual. Outcome indices included the percentage of ideal body weight, menstrual status, the Eating Disorder Examination (EDE) subscales scores, and the Children's Depression Rating Scale-Revised score.

RESULTS

Of the 20 patients recruited, 15 (75%) completed a full course of treatment. Intent-to-treat analyses showed significant improvement over time in the percentage of ideal body weight (t = -4.46, p =.000), menstrual status (p =.002), EDE Restraint (z = -3.02, p =.003), EDE Eating Concern (z = -2.10, p =.04), but not in EDE Shape Concern or Weight Concern subscales or Children's Depression Rating Scale-Revised score.

CONCLUSIONS

This open trial provides evidence that FBT can be successfully disseminated, replicating the high retention rates and significant improvement in the psychopathology of adolescent AN seen at the original sites.

Specialist supportive clinical management for anorexia nervosa

OBJECTIVE

This article presents the rationale for, and description of, a nonspecialized therapy for anorexia nervosa, called specialist supportive clinical management (SSCM).

METHOD

Clinical management and supportive psychotherapy models of treatment are outlined. SSCM is described, as it was delivered in a clinical trial of psychotherapies for adult women with anorexia nervosa.

RESULTS

The primary focus of SSCM for anorexia nervosa is the resumption of normal eating and the restoration of weight. Therapy aims to maintain a therapeutic relationship that facilitates the return to normal eating, and to enable other life issues that may impact on the eating disorder to be addressed.

CONCLUSION

Possible effective components of SSCM are discussed.

Role of therapeutic alliance in family therapy for adolescent anorexia nervosa

OBJECTIVE

The purpose of this study is to examine the role of therapeutic alliance in predicting treatment dropout, response and outcome in a cohort of adolescents with anorexia nervosa (AN) and their families who were treated using a manualized form of family-based therapy (FBT).

METHOD

Independent assessors scored early and late therapeutic alliances for patients and parents using the Working Alliance Inventory-Observer (WAIo). Outcomes were weights and scores on the subscales of the Eating Disorder Examination at the end of 12 months of FBT.

RESULTS

Therapeutic alliance throughout treatment was strong both for adolescents and for their parents. A strong early alliance with adolescents was associated with early treatment response in terms of weight gain. A strong early alliance with parents prevented dropout, whereas a strong late parental alliance predicted their child's total weight gain at the end of treatment.

CONCLUSION

Therapeutic alliance in both patients and parents treated with FBT is generally strong and likely contributes to treatment retention and treatment outcome.

Predictors of dropout and remission in family therapy for adolescent anorexia nervosa in a randomized clinical trial

OBJECTIVE

The purpose of this study is to explore the predictors of dropout and remission in the treatment of adolescent anorexia nervosa (AN) using family therapy.

METHOD

Data derived from a randomized clinical trial comparing short and long term family therapy for adolescents with AN were used. A rotated component analysis was employed to reduce the number of variables and to address problems of collinearity and multiple testing. Dropout was defined as participating in less than 80% of the assigned therapy. Participants were classified as remitted if they obtained an ideal body weight greater than 95% and a global eating disorder Examination score within two standard deviations of community norms at the end of 12 months.

RESULTS

Co-morbid psychiatric disorder and being randomized to longer treatment predicted greater dropout. The presence of co-morbid psychiatric disorder, being older, and problematic family behaviors led to lower rates of remission. A reduction of child behavioral symptoms, a decline in problematic family behaviors, and early weight gain were all within treatment changes that increased the chance of remission.

CONCLUSION

Co-morbid psychiatric disorder, family behaviors, and early response to treatment are important factors when predicting dropout and remission in family therapy for adolescent AN.

Is family therapy useful for treating children with anorexia nervosa? Results of a case series

OBJECTIVE

Research suggests that family-based treatment (FBT) is an effective treatment for adolescents with anorexia nervosa (AN). This retrospective case series was designed to examine its usefulness with younger children.

METHOD

Data were abstracted from medical records of 32 children with a mean age of 11.9 years (range 9.0-12.9) meeting diagnostic criteria for AN (n=29) and eating disorder not otherwise specified-restricting type (n=3) who were treated at two sites with FBT. Baseline characteristics, before and after weights, and Eating Disorder Examination (EDE) scores were compared with an adolescent cohort (N=78) with a mean age of 15.5 years (range 13.1-18.4) who were treated with FBT.

RESULTS

Children with AN share most disordered eating behaviors with their adolescent counterparts; however, their EDE scores are significantly lower than adolescents at both pre- and posttreatment assessments. Over the course of treatment with FBT, children showed statistically and clinically significant weight gain and improvements in eating disordered thinking as measured by the EDE.

CONCLUSION

FBT appears to be an acceptable and effective treatment for AN in children.

[Comparison of inpatient and day clinic treatment of anorexia nervosa]

OBJECTIVES

Explorative comparison of short term outcomes of day clinic and inpatient treatment for anorexia nervosa.

METHODS

N = 13 consecutively admitted day clinic patients (anorexia nervosa; DSM IV) were matched with N = 13 inpatients (variables: age, duration of illness, gender, admission weight, subtype of anorexia nervosa). Results at discharge were compared using defined outcome criteria as well as scores of the SCL-90-R and EDI-2.

RESULTS

After inpatient treatment significantly more patients showed a good outcome (predefined criteria). Effect sizes also pointed to a superiority of inpatient treatment.

CONCLUSIONS

In the initial phase of therapy the structured and holding environment of an inpatient unit may be favourable for severely underweight anorexic patients. The interpretation of these results is limited due to the small sample size.

Cognitive-behavioral therapy for adolescents with binge eating syndromes: a case series

OBJECTIVE

Published empirically based studies of psychotherapies for bulimia nervosa (BN) have been conducted solely with adult populations. The current study extends the extant literature by piloting a version of cognitive-behavioral therapy (CBT) for BN adapted for an adolescent population.

METHOD

The participants were referred for treatment for binge eating and purging behaviors at a university clinic. Patients received pretreatment and posttreatment interviews assessing the frequency of their binge eating and purge behaviors, and they also completed pretreatment and posttreatment assessments with the Eating Disorders Examination (EDE).

RESULTS

Results indicated significant reductions in the frequency of binge eating from pretreatment to posttreatment. Furthermore, all subscale scores of the EDE showed significant declines from pretreatment to posttreatment.

CONCLUSION

The authors concluded that CBT adapted for adolescents with bulimic symptoms appears to be a promising intervention worthy of further study in adolescents.

Twelve-year course and outcome predictors of anorexia nervosa

OBJECTIVE

The current study presents the long-term course of anorexia nervosa (AN) over 12 years in a large sample of 103 patients diagnosed according to criteria in the 4th ed. of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).

METHOD

Assessments were made at the beginning of therapy, at the end of therapy, at the 2-year follow-up, at the 6-year follow-up, and at the 12-year follow-up. Self-rating and an expert-rating interview data were obtained.

RESULTS

The participation rate at the 12-year follow-up was 88% of those alive. There was substantial improvement during therapy, a moderate (in many instances nonsignificant) decline during the first 2 years posttreatment, and further improvement from 3 to 12 years posttreatment. Based on a global 12-year outcome score, 27.5% had a good outcome, 25.3% an intermediate outcome, 39.6% had a poor outcome, and 7 (7.7%) were deceased. At the 12-year follow-up 19.0% had AN, 9.5% had bulimia nervosa-purging type (BN-P), 19.0% were classified as eating disorder not otherwise specified (EDNOS). A total of 52.4% showed no major DSM-IV eating disorder and 0% had binge eating disorder (BED). Systematic-strictly empirically based-model building resulted in a parsimonious model including four predictors of unfavorable 12-year outcome explaining 45% of the variance, that is, sexual problems, impulsivity, long duration of inpatient treatment, and long duration of an eating disorder.

CONCLUSION

Mortality was high and symptomatic recovery protracted. Impulsivity, symptom severity, and chronicity were the important factors for predicting the 12-year outcome.