Involuntary treatment of anorexia nervosa in Ireland: Challenges and changes in the legal framework.

A Change of Paradigm in the Treatment of Anorexia Nervosa? Not So Soon

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Involuntary treatment for anorexia nervosa (AN) is sometimes necessary and lifesaving but can be experienced negatively by some individuals. The purpose of this qualitative study was to better understand participants' perceptions about their experience with involuntary treatment for AN. Thirty adult participants, who had been treated involuntarily for AN in the past, completed self-report measures and qualitative interviews. Interview transcripts were coded using thematic analysis. Three themes were identified: (1) mixed perceptions about involuntary treatment, (2) the impact of involuntary treatment on external factors, including relationships, education, and employment, and (3) lessons learned from the experience. Participants who endorsed a positive shift in perspective regarding the need for involuntary treatment also reported favorable changes in their eating disorder recovery, whereas individuals whose perspective about their involuntary treatment remained negative, showed no changes in their recovery post-treatment. Involuntary treatment for AN was recognized, in retrospect, as being beneficial by individuals with AN who were doing well, but individuals who continued to struggle with their eating disorder reported negative consequences.

The Body Politic: Normal Female Adolescent Development and the Development of Eating Disorders

Introduction:The post-acute phase of anorexia nervosa (AN) following discharge from higher-level care is a high-risk period in which relapse rates are high and many individuals lack access to effective treatment. Even after acute nutritional stabilization, AN is characterized by decreased biobehavioral sensitivity towards general rewards and elevated sensitivity towards weight-loss cues. These reward patterns may continue to maintain eating disorder and comorbid affective symptoms. To address these gaps in the treatment literature for post-acute AN, we propose a randomized controlled trial comparing Positive Affect Treatment for AN (PAT-AN), a neuroscience-informed therapy adapted to target these reward imbalances in AN, to more standard psychoeducational and behavioral treatment (PBT) for eating disorders following acute care.Method:Adult participants (N = 80) with broad AN, including atypical AN, discharged from intensive treatment (e.g., residential, partial hospitalization) for AN within the past 6 months will be randomly assigned to 24 weeks of remotely-delivered PAT-AN or PBT. We will compare the feasibility, acceptability, and efficacy of each treatment to augment post-acute outpatient care for AN. A multimodal neurocognitive and self-report battery will assess eating pathology, comorbid symptom, and putative reward mechanism changes over the course of treatment (i.e., baseline, mid-treatment, post-treatment, three-month follow-up) and on a week-to-week basis.Discussion:This trial will, for the first time, directly target observed reward disturbances in the post-acute period of AN. Thus, this investigation has the potential to simultaneously evaluate a novel, efficacious treatment for AN and to further evaluate the role of reward dysfunction in AN maintenance.

Involuntary treatment may be a life-saving option for extremely severe anorexia nervosa (AN) in the context of life-threatening conditions and refusal of care. The long-term outcomes of patients undergoing involuntary treatment for AN are poorly understood. This study aims to explore quality of life, long-term outcomes and attitudes towards involuntary treatment in patients involuntarily treated for extremely severe AN. 23 patients involuntarily admitted for extremely severe AN (I-AN), and 25 voluntarily admitted patients (V-AN) were compared for body mass index (BMI), residual symptoms, quality of life, and attitudes towards treatment almost four years after discharge. In I-AN, clinical variables were also compared between admission and follow-up. At follow-up, weight restoration was higher in V-AN (p=0.01), while differences in quality of life, BMI, and mortality rates were not significant between I-AN and V-AN (p>0.05). In I-AN, BMI increased and weight-controlling strategies decreased at follow-up (p<0.05). Despite negative experiences of involuntary treatment, the perception of the necessity of treatment increased from admission to follow-up (p<0.01) and became comparable to V-AN (p>0.05). Involuntary treatment for AN does not appear to be a barrier to weight gain and clinical improvement, nor to long-term attitudes towards treatment.

The diagnostic category of eating disorders encompasses anorexia nervosa, bulimia nervosa, and the heterogeneous group of eating disorders not otherwise specified, most prominent among which is binge-eating disorder, currently detailed in research criteria in DSM-IV-TR and under consideration for inclusion as a separate diagnosis. In recent decades researchers have increasingly appreciated the multifaceted contributions to the etiology and pathogenesis of eating disorders, including genetic, familial, developmental, and psychosocial influences. Comorbidity with other axis I and axis II disorders is common, and medical comorbidity is of particular significance because of marked nutritional impairments that often accompany these disorders. Although the evidence-based treatment literature is sparse, particularly for anorexia nervosa, progress has been made with respect to nutritional, psychosocial, and psychopharmacological interventions for these disorders, and a growing consensus among clinicians has resulted in practice guidelines that attend to each of these dimensions.

We explored associations between clinical factors, including eating disorder psychopathology and more general psychopathology, and involuntary treatment in patients with anorexia nervosa. Our intention was to inform identification of patients at risk of involuntary treatment. This was a retrospective cohort study combining clinical data from a specialized eating disorder hospital unit in Denmark with nationwide Danish register-based data. A sequential methodology yielding two samples (212 and 278 patients, respectively) was adopted. Descriptive statistics and regression analyses were used to explore associations between involuntary treatment and clinical factors including previous involuntary treatment, patient cooperation, and symptom-level psychopathology (Eating Disorder Inventory-2 (EDI-2) and Symptom Checklist-90-Revised (SCL-90-R)). Somatization (SCL-90-R) (OR = 2.60, 95% CI 1.16-5.81) and phobic anxiety (SCL-90-R) (OR = 0.43, 95% CI 0.19-0.97) were positively and negatively, respectively, associated with the likelihood of involuntary treatment. Furthermore, somatization (HR = 1.77, 95% CI 1.05-2.99), previous involuntary treatment (HR = 5.0, 95% CI 2.68-9.32), and neutral (HR = 2.92, 95% CI 1.20-7.13) or poor (HR = 3.97, 95% CI 1.49-10.59) patient cooperation were associated with decreased time to involuntary treatment. Eating disorder psychopathology measured by the EDI-2 was not significantly associated with involuntary treatment. Clinical questionnaires of psychopathology appear to capture specific domains relevant to involuntary treatment. Poor patient cooperation and previous involuntary treatment being associated with shorter time to involuntary treatment raise important clinical issues requiring attention. Novel approaches to acute anorexia nervosa care along with unbiased evaluation upon readmission could mitigate the cycle of repeat admissions with involuntary treatment. Level III, cohort study.

Body image (BI) disturbances are one of the core symptoms of anorexia nervosa (AN). They have been shown to be associated with depression and anxiety at all treatment stages and are a reliable predictor of relapse. Considering the importance for the course of AN, direct targeting of BI disturbances is still underemphasized in the treatment of patients with AN. In this systematic review, conducted according to the PRISMA statement, the evidence on BI directed interventions in AN is synthesized. N = 11 studies investigating mirror exposure, video confrontation, virtual reality body exposure and treatment programs were analyzed. No systematic risk of bias within or across studies could be identified. The included studies show that BI directed interventions may be efficacious in improving BI related outcomes. However, the evidence regarding an additional effect of BI interventions added to established treatments for patients with AN, is unclear. The evidence base on BI interventions for patients with AN is scarce. It is not possible to identify types of BI intervention that can be seen as the most promising. Advantages of new technologies such as virtual reality or a combination of BI interventions with techniques for stress reduction are discussed.

This guideline watch reviews new evidence and highlights salient developments since the 2006 publication of APA’s Practice Guideline for the Treatment of Patients With Eating Disorders, 3rd Edition. The authors of this watch constituted the work group that developed the 2006 guideline. We find the guideline to remain substantially correct and current in its recommendations. The sole exception is a recommendation (with moderate-level confidence) for sibutramine for binge-eating disorder. In 2010, the U.S. Food and Drug Administration (FDA) withdrew approval for sibutramine because clinical trials showed increased risk of heart attack and stroke, and the manufacturer, Abbott Laboratories, subsequently withdrew this medication from the U.S. market. Noteworthy recent publications about the treatment of eating disorders include systematic reviews by the Agency for Healthcare Research and Quality (Berkman et al. 2006; Bulik et al. 2007); practice guidelines from international groups, including the Catalan Agency for Health Information, Assessment and Quality (Working Group of the Clinical Practice Guideline for Eating Disorders 2009), the World Federation of Societies of Biological Psychiatry (Aigner et al. 2011), and the German Society of Psychosomatic Medicine and Psychotherapy and the German College for Psychosomatic Medicine (Herpertz et al. 2011); and a 2011 guidance statement by the Academy for Eating Disorders, which was written by some of the authors of this

Background: Adolescents' early responses and overall outcomes during anorexia nervosa (AN) treatment may differ by patient gender, raising the question of whether evaluating clinical data during AN treatment may require different criteria. Methods: We investigated, using patient records, whether young men and young women with AN differed in terms of early treatment response (defined as weight change and variability within the first 14 days) and whether early treatment responses predicted treatment outcomes similarly across genders. Results: Weight changes predicted patient discharge weight across all gender groups. Weight variability predicted higher disordered eating psychopathology and higher body image insecurities at discharge. Gender differences emerged only for weight gain, which was more pronounced for young men, and gender modulated the effects of weight gain and variability on general psychopathology outcomes. Conclusions: The present findings suggest that early weight changes and weight variability are similarly important predictors of AN treatment outcomes in adolescents but also hint at possible gender differences in terms of the link between weight change and, respectively, variability on general psychopathology.

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

Anorexia Nervosa(AN), one kind of eating disorder charactered by abnormal eating patterns, low body weight, and weight and shape concerns, is an intractable psychiatric illness which has the highest mortality rates. The etiology of AN is complex, and the neurobiology mechanisms of AN remain unclear. Much of the research provided indications that the pathogenesis of AN is associated with the oxytocin(OT) functions. Summarizing the recent advances on OT in AN, a systematic review of OT research was conducted that it pertains to regulation of feeding, social activity, emotion and bone metabolism in AN. OT probably play an important role in the development and progression of AN. OT system disorder may be an state indicator rather than a trait indicator of AN. Because of the variety physiological effects and the complex effects on AN, OT has the potential applications, especially for the treatment of AN. Key words: Oxytocin; Anorexia nervosa; Eating disorder

BackgroundExploration of client identity negotiations during treatment for Anorexia Nervosa (AN) is a relatively new area of research. Research suggests that difficulties with identity negotiations may present as a barrier to treatment. This study sought to explore individuals’ identity negotiations during therapy sessions using Compulsive Exercise Activity Therapy (LEAP) combined with Cognitive Behaviour Therapy for Anorexia Nervosa (CBT-AN). Analysis focused on moments in therapy where individuals’ identities were dominated or defined by AN and where alternative identities could be generated.Method40 in-session transcripts from sessions at early, mid and end points of the CBT-AN (with LEAP) treatment were qualitatively analysed for nine of the 78 participants in the original randomised control trial. Through a constructivist framework, thematic analysis was used to identify surface and latent meanings and discursive material participants used to negotiate their identities in the context of therapy sessions.ResultsAnalysis of in-therapy transcripts generated two themes pertaining to identity negotiations: (1) troubled identities and (2) rebuilding identities and lives outside of AN. Early therapy sessions explored fragmented and AN dominated identities, including how AN was troubling to participants’ sense of self, contributed to conflicted identities, positioned them outside of normality, and was associated with isolated and othering identities. Within therapy sessions, participants engaged in a recursive process of shifting relationships with AN and themselves and building identities and lives outside of the AN identity. This included generating hopes for recovery and the future more frequently in mid- to late- therapy sessions.ConclusionIdentity negotiations evident in the therapeutic conversations aligned with the key components of the CBT-AN intervention, including addressing (1) the characterisation of oneself as ‘an anorexic’ and (2) the diversification of roles and activities to broaden and enhance self-concepts. Future developments of therapeutic interventions for AN would benefit from greater consideration of ways to assist individuals to more comprehensively address problematic identities, including uncovering identities hidden by the AN identity and generating preferred identities.Trial Registration: Ethics approval was obtained at the time of the initial study and for this embedded research by the HREC at the Western Sydney University (HR777332).

Anorexia nervosa (AN) is a mental and behavioral health condition characterized by an intense fear of body weight or fat gain, restriction of food intake resulting in low body weight, and distorted body image. Substantial research has focused on general anxiety in AN, but less is known about eating-related anxiety and its underlying neurobiological mechanisms. We sought to characterize anxiety-to-eat in AN and to examine neurometabolite levels in the dorsal anterior cingulate cortex (dACC), a brain region putatively involved in modulating anxiety-related responses, using edited magnetic resonance spectroscopy. Sixteen women hospitalized with AN and 16 women of healthy weight without a lifetime history of an eating disorder (healthy controls; HC) completed a computer-based behavioral task assessing anxiety-to-eat in response to images of higher (HED) and lower energy density (LED) foods. The AN group reported greater anxiety to eat HED and LED foods relative to the HC group. Both groups reported greater anxiety to eat HED foods relative to LED foods. The neurometabolite myo-inositol (myo-I) was lower in the dACC in AN relative to HC. In the AN group only, myo-I levels negatively predicted anxiety to eat HED but not LED foods and was independent of body mass index, duration of illness, and general anxiety. These findings provide new insight into the clinically challenging feature of eating-related anxiety in AN, and indicate potential for myo-I levels in the dACC to serve as a novel biomarker of illness severity or therapeutic target in individuals vulnerable to AN.