TREATMENT FOR ANOREXIA NERVOSA: ARE WE MISSING THE MARK?

Abstract

Eating Disorders (EDs) are serious psychological conditions where attitudes toward food, weight and body size or shape become distorted and severe disturbances in eating or exercise behaviours often occur (Fairburn and Harrison, 2003). In a categorical sense, EDs can be divided into four broad groups: Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge Eating Disorder (BED) and Other Specified Feeding and Eating Disorders (OSFED, previously EDNOS) (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, 2013). However, these categories are not discrete and it is not uncommon for sufferers to experience a spectrum of symptoms or crossover between diagnostic criteria. In the many years of ED research, if there is anything the scientific and clinical community have learned, it is that EDs are incredibly complex and multifaceted, with no one-size fits solution (Strober and Johnson, 2012). For the purpose of the current editorial, the authors have focused on AN, as the evidence and efficacy for treatment approaches remains limited.AN is an EDwith a reported lifetime prevalence of 0.3 to 1.5% in women and 0.1 to 0.5% in men (Hudson et al., 2007); however, given the secretive nature of the illness, it is highly likely these prevalence rates are underestimated (Hoek and vanHoeken, 2003). In terms of severity, AN meets all the criteria typically associated with diseases or illnesses perceived as severe, including prevalence, mortality, chronicity, functional impact, family dysfunction and societal effects (Touyz, 2011). AN is a chronic illness, with an average duration of five to seven years and the potential for life-long stmggle (Ben-Tovim et al., 2001). Longitudinal follow-up studies of more than 20 years have revealed mortality rates of approximately 20% (Steinhausen, 2002), the highest of any mental illness (Birmingham et al., 2005).Despite the suggestion in popular media, AN does not appear to be a modern phenomena, with origins dating back to the 13th century during the time of 'holy anorexia' (Pearce, 2004). However, regardless of advances in modern medical intervention progressing well beyond expectations for many physical and psychological conditions, there continues to be insufficient data to make strong evidence-bas ed recommendations regarding the treatment of adults with AN (APA, 2013; 2014; Watson and Bulik, 2013). Advances have been made in the treatment of adolescents (with a relatively short duration of illness), with three recommendations currently offered: Family-Based Treatment (FBT), outpatient services and inpatient services that combine refeeding and psychosocial interventions (NICE, 2004).An enhancedversion of Cognitive Behavioural Therapy (CBT-E), offered as an outpatient service and designed to affect ED psychopathology and external obstacles to change, proposes EDs share the same psychopathology or 'transdiagnostic' mechanisms (Fairburn et al., 2009). Based on this transdiagnostic model, it is assumed treatment of BN should be identical and as effective as for AN. However, whilst the efficacy of CBT-E has been substantiated in research trials with BN and EDNOS, only modest evidence exists for CBT with AN (Fairburn and Harrison, 2003). Certain researchers argue the suggestion BN and AN share common core psychopathology is misleading. For example, while patients with AN and BN both experience increased salience to weight and shape concerns, are preoccupied with food, attribute low self esteem to aesthetic features and display a tendency to overestimate their body size; the two conditions differ in intensity of symptoms, not the quality (or form) of the psychological state (Beumont and Touyz, 2003).In BN, it is argued these qualities or concerns are quintessence of the condition. For the BN sufferer, slenderness is desired to be 'happy' and 'healthy' and although he/she might be self-deprecating, this is due to associated behaviours, but is typically not the cause of the condition (Butow et al. …