Evidence-based Treatments for Anorexia Nervosa

This post is part of a series of guest posts on GPS by the graduate students in my Psychopathology course during Spring 2014. As part of their work for the course, each student had to demonstrate mastery of the skill of “Educating the Public about Mental Health.” To that end, each student has to prepare two 1,000ish word posts on a particular class of mental disorders, with one of those focusing on evidence-based treatments for those disorders and the other focused on a particular myth or misunderstanding about mental illness.

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Evidence-based Treatments for Anorexia Nervosa by Holli Norris

Anorexia nervosa (referred to as only anorexia from here forward) is a mental disorder characterized by low body weight, a fear of gaining weight and disturbances in the way that an individual sees themselves in terms of weight and shape. Individuals who suffer from anorexia will resort to extreme measures in order to maintain their already low body weight or to continue losing weight. These individuals may use methods to remove calories that they have already eaten from their bodies such as self-induced vomiting, laxatives, or enemas. Others may restrict what they eat to certain foods they perceive as low calorie or restrict the total number of calories consumed.

Anorexia can lead to a state of semi starvation in those that suffer from it. The consequences of this can have drastic consequences on the health of the individual. These consequences can range from dry skin and brittle hair to more severe and permanent such as osteoporosis and organ damage. For some of these individuals the adverse health effects experienced can even lead to death. For this reason anorexia and eating disorders are extremely dangerous and it is important that individuals with anorexia seek proper treatment. Unfortunately, there have been few controlled studies testing treatments for anorexia compared to some more common disorders. However there are several promising treatments that have shown to be efficacious in smaller studies.

One promising approach for treating anorexia in adolescents is Family Based Therapy (FBT). In this, the individual’s family is involved in the treatment and recovery processes, especially the parents. One form of FBT that has shown to be effective is the Maudsley approach. This approach is specific to eating disorders and consists of three distinct phases. In the first phase of treatments focuses on restoring the individual’s weight and allowing them to become physically healthy. The therapist will observe the patterns on interaction between the family members during meal times. The parents will them be coached by the therapist to be encourage the adolescent to eat more and to convey that continuing the inappropriate eating behaviors is not an option. The parents are expected to remain noncritical of the adolescent and maintain that the eating disorder is not the child’s fault. During this phase the main control over eating behavior of the individual lies with the parents.

The second phase of treatment focuses on returning the control over eating to the individual. In this phase the eating behavior of the adolescent is still closely monitored, but control is gradually given back to the adolescent. It is during this phase that other issues that had an effect on the disorder, but do not directly relate to eating behaviors can be addressed. After the individual is able to maintain a weight no lower than 5% below the normal weight for his or her age and height and the inappropriate restrictive and compensatory behaviors have ceased the individual can then move on to phase three.

In phase three the individual focuses on developing a healthy adolescent identity and the challenges faced by all adolescents in this time in their life outside of the eating disorder. Although this method has shown effective in clinical trials with adolescents it does have its downsides. For example it is extremely intensive in that it requires extremely close 24 hour monitoring of the individual for the first phase of treatment. This method is also generally useful for the treatment of adolescents and may not be feasible for older individuals. The total treatment time for this approach is usually around 12 months and takes place over 15-20 sessions.

Another commonly used and research supported treatment for anorexia is Cognitive Behavioral Therapy (CBT). CBT is a form of therapy in which the relationship between thoughts, emotions, and behaviors are examined. This is a collaborative method of therapy in which the therapist and the patient work together in a goal-directed and problem-focused fashion. The patient is taught to challenge the irrational thoughts and beliefs that underlie maladaptive behavior in order to make the individual aware of them and replace them with more realistic and rational ones.

For eating disorders a more specific form of CBT, called enhanced CBT (CBT-E), is used. There are two forms of CBT-E, the focused form (CBT-EF) which is used specifically for eating disorder pathology and a broad form (CBT-EB) which addresses both eating disorder pathology and external factors that block change. There are also two levels of intensity of CBT-E: one for patients that are not underweight and another for those that are significantly underweight. As being underweight is one of the criteria for anorexia nervosa the more intense 40 week 40 session program is generally used.

Like FBT CBT-E is also accomplished in three phases. During the first phase a foundation for the treatment is created. This is done by engaging the individual in treatment and educating them about the disorder as well as creating a collaborative plan for treatment. The client is also asked to eat regularly and to weigh in at each session with the therapist. During stage two the individual’s progress is reviewed as well as any problems that may have not been addressed. The third step is the time where the main treatment takes place. In this stage the maladaptive mechanisms and processes in thought and emotion that are maintain the disordered eating behaviors are addressed. These are examined and challenged in order to allow the individual to think more rationally about food and weight in order to recover from their illness.

Eating disorders have the potential to be deadly for those that suffer from them. It is this reason that it is extremely important that those with eating disorders seek treatment. Due to the nature of the disorder it is necessary for treatment to address both physical and mental health. Furthermore it is important that the treatment chosen be one that is firmly grounded in research. Although the current body of research is limited in the area of anorexia there are treatments that have shown to be effective in aiding recovery.