Anorexia Nervosa

Historical and geographical studies suggest that anorexia nervosa has occurred wherever there are humans. The first formal medical account is in Richard Morton's Phthisiologia (1689). Anorexia nervosa responds to the same precipitants as bulimia but depends on a physiological capacity to tolerate extreme starvation, which may be genetic. The core psy-chopathology of anorexia nervosa is overwhelming concern about body shape and weight. Phobia of fatness increases as weight decreases. The controversial 'body image distortion' does not amount to a delusion (and is unresponsive to anti-psychotic drugs) but resembles an obsessive-compulsive conviction, attracting to itself all negative attributions generated in the course of everyday life. Current diagnostic criteria for anorexia nervosa require that:

• Body weight is maintained at least 15 % below that expected (in adults, BMI 17.5 or less).

• This occurs either through sheer dietary restraint (restricting sub-type) or by restraint together with self-induced purging ('bulimic' subtype-although 'binges' are often simply episodes of unplanned eating). Both groups may compulsively over-exercise.

• In women menstruation ceases (or never starts). Men have atrophied genitalia and loss of erections.

Diagnostic criteria have changed over time, to include less emaciated individuals. Earlier criteria demanded weight 25 % below expected. Some women apparently in the 'normal' weight range have starved from a high weight that is their own norm and experience similar symptoms - so-called 'cryptic' anorexia. It has been suggested that amenorrhoea should not be obligatory (and is often masked by the contraceptive pill). Some women menstruate and give birth at unhealthily low weight.

The widening of the diagnosis is problematic when considering epidemiological data -prevalence increases overnight! - and for prognostic studies. For instance, Theander's (1985) classic outcome studies are no longer directly applicable to all who are diagnosed with anorexia nervosa today.

Anorexia Nervosa: The Evidence Base

It is ironic that the most lethal of all psychiatric disorders should be the Cinderella of research - there are few randomised controlled trials of treatment for anorexia nervosa. However, psychotherapies have a unique role in anorexia - drug treatments have repeatedly been found ineffective, as well as potentially dangerous to starved patients, except in the reduction of relapse (Kaye et al., 1991).

It is hard to engage subjects with anorexia for treatment, let alone research. Early in the disorder symptoms are ego-syntonic; later on anorexia takes over the patient's whole identity - the prospect of relinquishing it is terrifying. Serfaty (1999) recruited 35 subjects to compare CBT with dietary advice in anorexia. Two of the CBT group and all of the dietary group dropped out of treatment!

We cannot assume that subjects who drop out of treatment are worse off. Victims of rigid behavioural refeeding programmes who 'eat their way out of hospital' and then starve again may be at greater physical risk than before and certainly 'immunised' psychologically against further treatment. A recent Australian survey found that overall prognosis for patients with anorexia (and other eating disorders) is independent of whether treatment is received or not (Ben-Tovim et al., 2001). Therapy may be an expensive irrelevance, or perhaps some treatment does help while some is downright harmful.

Coercive approaches, which march roughshod over the anorexic demand for control and self-respect, make patients more likely to identify with and cling on to the anorexia. Gowers et al. (2000) found that hospital admission was strongly correlated with poor outcome. Ramsay etal. (1999) have shown that long-term prognosis is worse for patients compulsorily detained in an in-patient facility than for those treated voluntarily in the same unit, with more deaths in the former group. However, the use of brief hospital admissions to acute medical wards at times of life-threatening crisis or following overdose may be associated with lower mortality (De Filippo, Signorini & Bracale, 2000).

The weight of the patient is a deceptively clear outcome measure in AN. Certainly a healthy weight is necessary but it should reflect the patient's psychological and hence physical recovery. Unless patients are responsible for their own food intake, weight is merely the transient result of the efforts of staff. Short-term weight restoration is a very poor predictor of long-term outcome.

Follow-up times must be very long indeed to measure real benefits in anorexia. Theander (1985) and colleagues, who have followed cohorts over several decades, find that a substantial proportion of cases take six to 12 years to resolve, and a few take longer still. Lowe et al. (2001) have recently shown that full recovery is possible even after 21 years of chronic severe AN. Late relapse also occurs.

Anorexia Nervosa: Components of Treatment

Anorexia nervosa is precipitated as a psychological coping mechanism against, for instance, developmental challenges, transitions, family conflicts and academic pressures. However, the ensuing sequelae of self-starvation may involve a constellation of medical professionals as well as psychotherapists - not just a treatment but a co-ordinated campaign.

Manuals, such as those for BN, cannot address the chronic and complex nature of AN. Integrated care pathways (ICPs) are designed to standardise and guide management of whole episodes of medical illness (Coffey et al., 1992). Detailed guides to formulating optimal sequencing and collaborative multi-disciplinary efforts for people with AN are starting to appear. Lock (1999) has described the development and first three years of implementation of an ICP for adolescents with AN.

Evidence at present favours longer term, more wide-ranging, complex therapies, using psychodynamic understanding and, often, systemic principles. Whatever the therapist's core model, or chosen medley of techniques, three main strands must be juggled throughout therapy of anorexia nervosa:

1. Motivational Issues, and Building a Collaborative Relationship

Early on, especially with younger patients, motivation for treatment tends to lie with parents, school teachers or medical professionals. The guiding principle of motivational enhancement is to acknowledge and explore rather than fight thepatient's ambivalence about recovery. The therapist discovers the benefits of the anorexia to the patient and explores other ways to achieve or renounce these. Therapy is more effective when the therapist collaborates with the patient against the anorexia. Such a relationship may allow necessary hospital admissions or other essential treatments without the need to invoke the Mental Health Act - or at least permit the survival of a working relationship even after 'sectioning'. Motivation is not an all-or-nothing battle to be won before therapy can start but an active strand throughout treatment.

2. Medical Monitoring and Attainment of a Healthy Stable Weight

There are two contrasting approaches to weight gain. In countries where all treatment is given in hospital, refeeding is an early intervention. Subsequent therapy helps patients tolerate, maintain or regain normal weight. This may be the preferred approach for children and young adolescents, where long periods at low weight are detrimental to growth and development. Hospital refeeding requires physiological fine-tuning and may expose the patient to iatrogenic complications such as infections and the sequelae of passing tubes. There may also be a risk of 'learning' anorexic behaviours or becoming unhealthily immersed in pathological cultures on wards. It may be possible to avoid both Scylla and Charybdis if the family is able to accept the task of gradual refeeding.

A second approach temporarily accepts low weight, if stable and subject to medical monitoring, while patients take responsibility for their own refeeding. It is helpful to provide dietetic expertise separately from the psychotherapy. Weight gain is slower but more likely to be maintained. This approach avoids many iatrogenic risks. However, clinicians still need access to medical wards for physical emergencies. Medical safety requires weight stability. There is no magic safe cutoff weight or BMI. Some outpatients maintain BMIs below those specified in old medical textbooks to be incompatible with life. Analyses of survival show that death is unusual where low weight is maintained purely by starvation (Herzog et al., 2000; Lowe et al., 2001). Deaths are more likely at BMIs of 13 or 14 if there is rapid weight fluctuation, frequent purging or co-morbid substance abuse, than at stable BMI even below 12.

Adolescents, especially, find it difficult to appreciate links between starvation and other symptoms and it is counterproductive to try to frighten the patient into getting better. There is no good evidence that psychoeducational strategies are effective either preventatively or as treatment for AN. However, results shared with the patient in a concerned and constructive way provide an extra perspective on the advantages and disadvantages of remaining anorexic. The classic Minnesota Starvation Study of Keys et al. (1950) is available in accessible digests (for example, Garner & Garfinkel, 1997: Ch 8; Treasure, 1997: Ch. 11) both for therapists and their patients.

Someone needs to monitor and communicate the patient's weight on a regular basis (at least weekly), both for physical safety and so that links can be made within therapy. Patients who 'work' calmly and cheerfully in therapy often turn out to have lost rather than gained weight.

3. Interpersonal and Life Skills

Patients need a new repertoire of coping strategies if they are to renounce anorexic responses. Many patients become 'stuck' just under a normal weight range until they gain the confidence to face the social and sexual jungle of adult life. Assertiveness training, DBT skills groups, relaxation, mindfulness and IPT are offered but still lack formal evaluation. Family work is the only well-researched intervention to show favourable impact.

Family Therapy

The Maudsley Hospital family therapy studies are an honourable exception to the general lack of research in AN. They represent the work of the same group, so it is hard to tease out differential effects of therapeutic techniques from the personal qualities of the highly trained and experienced individuals concerned. Early studies showed that family therapy gave better results than individual therapy for teenage girls with relatively recent onset anorexia. (Russell et al., 1987) Further studies showed that while conjoint family therapy -if tolerated - gave the best results in terms of family psychological adjustment, weight gain was greater when families were seen separately from the affected patient (Eisler et al., 2000). Both family interventions were more effective than individual work.

The 'separated family therapy' model involved straightforward supportive psychoeduca-tional counselling, and proved particularly useful where there were high levels of expressed emotion in the families. (These families were unable to benefit from traditional family therapy.) More recently, Maudsley professionals have piloted 'multi-family groups' in the treatment of resistant eating disorders (Dare & Eisler, 2000). Work from Toronto (Geist et al., 2000) supports the effectiveness of both family therapy and 'family group psychoedu-cation' for adolescents with newly diagnosed eating disorders, and highlights the economic benefits of the latter.

Individual Dynamic Therapy and Cognitive Analytic Therapy

The Maudsley group have compared individual focused dynamic therapy with dynamically informed family therapy and with individual cognitive analytic therapy (CAT) in a sample of low-weight outpatients over the course of a year (Dare et al., 2001). 'Controls' were seen weekly by psychiatric trainees supervised by a senior therapist. Best results were achieved by the dynamically informed therapies, both family and individual. However, the same highly experienced therapists who carried out the family studies described above gave both treatments. Cognitive analytic therapy was administered by a group of fairly experienced, trained therapists and gave intermediate results. The study faced the challenge of studying severely ill anorexic patients managed as outpatients and demonstrated the benefits of continuity of therapist and of therapist expertise. Nothing can be concluded about the specific model of therapy provided.

Anorexia Nervosa: Clinical Practice

The majority of teenagers who develop AN make a good recovery in the relatively short term.

Case Illustration

Annette, a 15-year-old schoolgirl, was brought to the clinic by her worried parents. Her weight was falling again after a precipitous weight loss two years earlier, when her grandmother died. She menstruated for only six months before her periods stopped. She failed to grow as tall as expected. She performed brilliantly in examinations, though, and said she felt 'fine'. Teachers expressed concern and she was taken out of sports. They now suggested that she seek help before returning to school to take higher exams. BMI was 15.2. DEXA scan showed bone density considerably lower than expected.

Her father declined to take time out of work but her mother met with the therapist with Annette's permission. Annette worked on a series of motivational exercises, writing about her anorexia as if it were a friend and then as an enemy. Her therapist left the service but she continued to meet with a dietitian who helped design meal plans. She managed to stabilise her weight but became terrified if the scales showed the slightest increase. Her parents discovered that she was vomiting to offset extra calories.

It was agreed that Annette should start cognitive analytical therapy with a new nurse therapist. She was fascinated by the diagrams and carried her therapist's reformulation letter, like a talisman. Her weight remained low, though, and she became depressed as former classmates moved on. Her father was now more concerned and pushed for intensive treatment.

Annette reluctantly agreed to attend a full-time day-patient programme with staff-supported meals and regular family sessions. Before discharge the family was encouraged to reinstitute family meals - these had not been possible for several years, and were even now difficult. Throughout the programme and after discharge Annette continued to work with the same individual CAT therapist. Therapy was stormy and Annette became 'stuck' for a while around the weight at which menstruation returned. Finally she managed to achieve a healthy weight and returned to school.

Sometimes a 'course' of therapy for anorexia nervosa will need to be conceived in terms of years rather than weeks or months, and goals may shift over time. It is more realistic for some patients to aim for stability and damage limitation rather than full physical and psychological cure. Staff need skills of containment, patience and support rather than the more challenging techniques characteristic of structured psychotherapies.

Case Illustration

Anna, a 39-year-old woman, suffered from severe anorexia nervosa since the age of 13. She had menstruated for less than a year when she reduced her weight to 28 kg (BMI 13) with no obvious precipitant. She was a much-loved only child, born to elderly parents after a series of miscarriages.

For most of Anna's teens she was subjected to assertive behavioural regimes in a paedi-atric ward. She reached 'target weights' only transiently and once discharged would quickly lose weight. On one admission she 'learned' purging behaviours from another patient and it was finally agreed that admission was detrimental. She was discharged back to the care of her GP and things stabilised sufficiently for her to complete a history degree. Then her father died. She was admitted - voluntarily - to a medical ward as an emergency, dangerously emaciated and dehydrated, although no longer purging. For the first time, she asked for therapy.

She agreed to transfer to a specialist unit where she was obliged to take prescribed meals, but was not tube fed. She attended motivational and self-image groups as well as drama therapy and volunteered for trials of treatments for her now severe osteoporosis. She formed a close attachment to her individual CAT therapist and became anxious about relapse when she returned home, hundreds of miles away. She decided to enrol for a higher degree in the university nearest her clinic.

She moved into a hostel for a year with fellow patients, continuing to attend the unit as an out-patient. She initially lost weight but then stabilised. She remained amenorrhoeic and had lost height as a result of vertebral collapse from osteoporosis. She lived an austere but fairly contented life, coping well with the death of her mother. She remained in touch with the specialist unit, transferring her attachment to new therapists when staff moved away.

Behavioural, Cognitive and Interpersonal Therapies for AN

Discredited behavioural regimes for anorexia involved incarceration in hospital with removal of all 'privileges' - such as visiting, TV, independent use of bathroom - and their return as reinforcement for weight gain. There is no evidence for lasting benefit. Behavioural principles are implicit, though, when realistic concerns are used to limit anorexic behaviour. For instance, ballet schools and athletic associations refuse to allow individuals below a certain BMI to participate. School trips and holiday plans, too, may depend on stable weight.

There are convincing cognitive models for the development and maintenance of AN (Garner & Bemis, 1985) but CBT for anorexia requires a therapist experienced in the field of eating disorders as well as in CBT to adapt the model and sidestep pitfalls. The controlled trial of Channon et al. (1989) showed no difference in outcome between behaviour therapy and cognitive therapy. A study in New Zealand has given disappointing preliminary results for both CBT and IPT in comparison with treatment as usual (Mcintosh & Jordan, 2005). It is certainly time to design and test out sophisticated twenty-first century models of CBT for AN, and to re-examine the components of integrated packages of care so that we can mobilise more powerful treatments.

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