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Anorexia Nervosa

Child and Adolescent Disorders

II. Specific Disorders

  1. Cynthia M. Bulik1,
  2. Kimberly A. Brownley2,
  3. Jennifer R. Shapiro3,
  4. Nancy D. Berkman4

Published Online: 25 JUN 2012

DOI: 10.1002/9781118156391.ebcp001025

Handbook of Evidence-Based Practice in Clinical Psychology

Handbook of Evidence-Based Practice in Clinical Psychology

How to Cite

Bulik, C. M., Brownley, K. A., Shapiro, J. R. and Berkman, N. D. 2012. Anorexia Nervosa. Handbook of Evidence-Based Practice in Clinical Psychology. 1:II:25.

Author Information

  1. 1

    University of North Carolina School of Medicine

  2. 2

    University of North Carolina at Chapel Hill

  3. 3

    Santech, Inc

  4. 4

    RTI, International

Publication History

  1. Published Online: 25 JUN 2012

1 Overview of the Disorder

  1. Top of page
  2. Overview of the Disorder
  3. Sources of Information for This Report
  4. Weight Restoration/Nutritional Rehabilitation
  5. Cognitive Behavior Therapy
  6. Family-Based Therapy
  7. Cognitive Analytic Therapy
  8. Summary
  9. References

Anorexia nervosa (AN) is a serious psychiatric illness characterized by an inability to maintain a normal healthy body weight (< 85% of ideal body weight [IBW]). By virtue of its toll on physical health and body composition, in particular, it is the most recognizable eating disorder. Younger individuals who are still growing fail to make expected increases in weight (and often height) and bone density. Somewhat remarkable, despite increasing emaciation, individuals with AN continue to desire additional weight loss, may see themselves as fat even when severely underweight, and often engage in unhealthy behaviors to lose weight (e.g., purging, dieting, excessive exercise, fasting). Psychologically, AN is marked by shape and weight playing a central role in self-evaluation. Amenorrhea of at least 3 months is a diagnostic criterion; however, there do not appear to be meaningful differences between individuals with AN who do and do not menstruate (Attia & Roberto, 2009; Gendall et al., 2006; Watson & Andersen, 2003). AN presents either as the restricting subtype in which low weight is achieved and maintained through caloric restriction and increased physical activity only, as well as the binge-purge subtype in which the individual regularly engages in binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). Associated personality features, many of which exist premorbidly, include perfectionism, obsessionality, anxiety, harm avoidance, and low self-esteem (Wonderlich, Lilenfeld, Riso, Engel, & Mitchell, 2005).

AN is commonly comorbid with major depression (Halmi et al., 1991; Walters & Kendler, 1995) and anxiety disorders (C. Bulik, Sullivan, Fear, & Joyce, 1997; Kaye et al., 2004). Several studies have shown that anxiety disorders often predate onset of the eating disorder (C. Bulik et al., 1997; Kaye et al., 2004), and depression often persists postrecovery (Sullivan, Bulik, Fear, & Pickering, 1998).

1.1 Diagnostic Criteria and Clinical Characteristics

Two sets of diagnostic criteria for AN are presented in Table 1. These criteria, from the Diagnostic and Statistical Manual for Mental Disorders III-R and IV (American Psychiatric Association [APA], 1987, 1994), represent the most common criteria used in recent randomized clinical trials (RCT) of AN.

Table 1. DSM-IV-TR Diagnostic Criteria for Anorexia Nervosa
SourceDiagnostic Criteria
  1. a

    Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (Copyright © 2000). American Psychiatric Association.

DSM-III-R Criteria for Anorexia Nervosa (307.10)

A. Refusal to maintain body weight over a minimal normal weight for age and height (e.g., weight loss leading to maintenance of body weight 15% below that expected or failure to make expected weight gain during period of growth, leading to body weight 15% below that expected).

B. Intense fear of gaining weight or becoming fat, even though underweight.

C. Disturbance in the way in which one's body weight, size, or shape is experienced (e.g., the person claims to “feel fat” even when emaciated, believes that one area of the body is “too fat” even when obviously underweight).

D. In females, absence of at least three consecutive menstrual cycles when otherwise expected to occur (primary and secondary amenorrhea). (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.)

DSM-IV Criteria for Anorexia Nervosa (307.10)

A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected).

B. Intense fear of gaining weight or becoming fat, even though underweight.

C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.

D. In postmenarchal females, amenorrhea (i.e., the absence of at least three consecutive cycles). (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.)

Specify Type:

Restricting Type: During the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Binge Eating/Purging Type: During the current episode of anorexia nervosa, the person has regularly engaged in binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

1.2 Demographic Variables

Based on data from the National Comorbidity Study-Replication, the mean prevalence of AN in adults (ages 18 and older) living in the United States is 0.9% among women and 0.3% among men (Hudson, Hiripi, Pope, & Kessler, 2007). Prevalence of subthreshold AN, defined as one criterion short of threshold, is greater—ranging from 0.37% to 1.3% (McKnight Investigators, 2003; Wittchen, Nelson, & Lachner, 1998). Estimates do not exist for the prevalence of AN or subthreshold AN in children under age 18 living in the United States.

There is some controversy regarding the incidence of AN, with some studies suggesting an increased incidence of AN in recent years (Eagles, Johnston, Hunter, Lobban, & Millar, 1995; Jones, Fox, Babigan, & Hutton, 1980; Lucas, Beard, O'Fallon, & Kurland, 1988; Milos et al., 2004; Møller-Madsen & Nystrup, 1992; Szmukler, 1985; Willi & Grossman, 1983) and others reporting stable rates (Hall & Hay, 1991; Hoek, 1991; Jorgensen, 1992; Nielsen, 1990). The most common age of onset is between 15 and 19 years (Lucas, Beard, O'Fallon, & Kurland, 1991), although anecdotal reports suggest an increase in the prepubertal period (S. Gowers, Crisp, Joughin, & Bhat, 1991) and in older adults (Beck, Casper, & Andersen, 1996; Inagaki et al., 2002). AN afflicts females disproportionately, with a sex ratio of approximately 9:1 (American Psychiatric Association, 2000).

1.3 Impact of Anorexia Nervosa

Psychiatric and medical consequences. AN carries with it multiple medical and psychological sequelae, including depression, anxiety, social withdrawal, fatigue, and multiple medical complications (Halmi et al., 1991; Kaplan, 1993; Katzman, 2005; Sharp & Freeman, 1993). AN takes a social toll as well. Due to the prolonged and all-encompassing nature of the illness, many individuals miss out on the normal developmental milestones associated with adolescence (C. M. Bulik, 2002). The most detailed longitudinal cohort study followed individuals with AN and their age-matched peers for 20 years in Göteborg, Sweden. After 5 years, those who had had AN were more likely to have personality disorders (especially avoidant, dependent, obsessive-compulsive, or passive-aggressive) as well as higher rates of obsessive-compulsive disorder, Asperger's syndrome, any autism-like condition, and empathy disorder (I. Gillberg, Råstam, & Gillberg, 1995). At 10 years these observations persisted (Råstam, Gillberg, & Wentz, 2003; Wentz, Gillberg, Gillberg, & Råstam, 2001; Wentz, Gillberg, Gillberg, & Råstam, 2000), and the AN group had a higher lifetime prevalence of depression (Ivarsson, Råstam, Wentz, Gillberg, & Gillberg, 2000).

A history of AN has also been associated with subsequent problems with reproduction (C. Bulik, Sullivan, Fear, Pickering, & Dawn, 1999), osteoporosis (Rigotti, Neer, Skates, Herzog, & Nussbaum, 1991), and continued low body mass index (BMI).

Recovery. A common question is whether individuals can recover from AN. In the aforementioned Swedish follow-up study (C. Gillberg, Råstam, & Gillberg, 1994a; C. Gillberg, Råstam, & Gillberg, 1994b; Råstam, Gillberg, & Gillberg, 1995), at 5 years, approximately one half of individuals with AN were considered to be recovered. A full 59% had no eating disorder diagnosis and 41% had a good outcome, according to the commonly used Morgan-Russell general outcome scale. Six percent continued to meet diagnostic criteria for AN, 22% had bulimia nervosa, and 14% met criteria for eating disorder not otherwise specified. At 10 years (Nilsson, Gillberg, Gillberg, & Råstam, 1999; Råstam, Gillberg, & Wentz, 2003; Wentz, Gillberg, Gillberg, & Råstam, 2001), 27% of individuals met criteria for some eating disorder diagnosis. Thus, within 10 years of study entry, recovery occurred in the majority of patients, but a significant minority continued to struggle with active symptoms of the disorder.

These results were mirrored in a New Zealand study that contacted patients after 12 years for follow-up assessments and compared their outcomes with age-matched individuals from the same community (C. Bulik, Sullivan, Fear, & Pickering, 2000; Sullivan, Bulik, Fear, & Pickering, 1998). Of the AN patients, 30% were fully recovered at follow-up; 21% continued to have an eating disorder, including 10% who continued to meet diagnostic criteria for AN. Women with histories of AN continued to have lower BMIs, higher scores on scales of disordered eating, and the desire to be at a lower weight.

Relapse is a common problem for individuals with AN. A Danish study assessed relapse in 121 patients 4 to 22 years posttreatment. Using life-table methods, 14% of the population relapsed in the first year. For those left to evaluate in subsequent years, the relapse rate declined below 4% per year (Isager, Brinch, Kreiner, & Tolstrup, 1985). In a separate study that defined relapse as meeting full criteria for AN for at least 1 week following full recovery, 40% of patients experienced a relapse after a median of 8 years (Herzog et al., 1999).

Mortality. AN has the highest mortality rate of any psychiatric illness (Sullivan, 1995). The standardized mortality ratio ranges from 1.36 (among females 20 years following treatment) to 30.5 (among females less than 1 year following treatment) (Birmingham, Su, Hlynsky, Goldner, & Gao, 2005; Eckert, Halmi, Marchi, Grove, & Crosby, 1995; Herzog et al., 2000; Keel et al., 2003; Lee, Chan, & Hsu, 2003; Møller-Madsen, Nystrup, & Nielsen, 1996). Based on an analysis of studies published between 1966 and 1995, premature all-cause death risk in individuals with AN was 5 times higher than expected, due to increased rates of premature death from both natural (4 times higher than expected) and unnatural (11 times higher than expected) causes (Harris & Barraclough, 1998). Notably, premature death risk due to suicide was 32 times higher than expected, and approximately 65% of deaths due to natural causes were directly attributed to starvation. Thus, AN is a pernicious disorder with serious and sometimes life-threatening consequences.

2 Sources of Information for This Report

  1. Top of page
  2. Overview of the Disorder
  3. Sources of Information for This Report
  4. Weight Restoration/Nutritional Rehabilitation
  5. Cognitive Behavior Therapy
  6. Family-Based Therapy
  7. Cognitive Analytic Therapy
  8. Summary
  9. References

The evidence base for treatments for AN is limited. In order to present the evidence base for AN treatment, we draw from three sources of information. No meta-analyses are available combining results from psychosocial interventions for AN.

  1. Consensus Panel Recommendations from the American Psychiatric Association (APA) and the American Academy for Pediatrics (AAP) on the treatment of AN.

  2. The Agency for Healthcare Research and Quality (AHRQ) evidence-based report on treatments for AN. On behalf of the National Institutes of Health (NIH) Office of Research on Women's Health, the National Institute of Mental Health, and the Health Resources and Services Administration, AHRQ commissioned the RTI International-University of North Carolina Evidence-Based Practice Center (RTI-UNC EPC) to conduct an extensive systematic review of the literature on treatment and outcomes of AN, bulimia nervosa, and binge eating disorder (Berkman et al., 2006). We draw on the results of this review of RCTs of behavioral interventions for AN in order to present the core evidence base for treatment of this disorder.

  3. For purposes of this chapter, we conducted an evidence report update, employing the identical search process of the initial AHRQ evidence-based review to identify all studies published between 2005 and March 2008.

The AHRQ evidence-based report was developed with ongoing consultation with a Technical Expert Panel (TEP) comprised of 10 individuals (researchers, practitioners, and a patient advocate). Four key questions guided the evidence-based review and are relevant to the present chapter.

  1. What is the evidence for the efficacy of treatments or combinations of treatments for AN?

  2. What is the evidence of harms associated with the treatment or combination of treatments for AN?

  3. What factors are associated with efficacy of treatment among patients with AN?

  4. Does the efficacy of treatment for AN differ by sex, gender, age, race, ethnicity, or cultural group?

Complete methods of the review can be found in the evidence report (Berkman et al., 2006). In this chapter, we focus only on psychosocial interventions for AN; outcome categories included eating, psychiatric and psychological, and biomarker measures.

In order to identify all relevant literature, we searched six major databases: AGRICOLA (National AGRICultural OnLine Access), CINAHL (Cumulative Index to Nursing and Applied Health), Cochrane Collaborative libraries, ERIC (Educational Resources Information Center), MEDLINE (National Library of Medicine's premier bibliographic database covering the fields of medicine, nursing, dentistry, veterinary medicine, the health-care system, and the preclinical sciences), and PsycINFO (the American Psychological Association abstract database of psychological literature from the 1800s to the present). We generated Medical Subject Heading (MeSH) search terms for MEDLINE searches and used comparable terms for other databases. MeSH terms included anorexia and anorexia nervosa. We limited our searches by type of study, including RCT, single-blind, double-blind, and cross-over designs. We also asked experts in the field and the TEP for additional articles that our searches may not have captured. Table 2 summarizes the inclusion criteria for selected abstracts.

Table 2. Inclusion Criteria for AHRQ Report and Updated Review
CategoryCriteria
Study population

Humans

All races, ethnicities, and cultural groups

10 years of age or older

Study settings and geographyAll nations
Time periodPublished from 1980 to the present
Publication criteria

All languages

Articles in print

Articles in the “gray literature,” published in nonpeer-reviewed journals, or unobtainable during the review period were excluded.

Admissible evidence (study design and other criteria)

Original research studies that provide sufficient detail regarding methods and results to enable use and adjustment of the data and results.

Anorexia nervosa must be diagnosed according to DSM-III, DSM III-R, DSM-IV, ICD-10, Feighner, or Russell criteria.

Relevant outcomes: eating related, psychiatric or psychological, and biomarker measures must be able to be abstracted from data presented in the papers.

Eligible study designs include:

Randomized controlled trials:
  • Double-blinded, single-blinded, and cross-over designs (data from prior to the first cross-over).

  • Anorexia nervosa studies: initiated with 10 or more participants and followed for any length of time.

Outcomes studies:
  • Observational studies, including prospective and retrospective cohort studies and case series studies, with and without comparison populations.

  • Disease population must be followed for a minimum of 1 year.

  • Disease population must include 50 or more participants at the time of the analysis.

We reviewed each abstract systematically against the a priori criteria presented in Table 2 to determine inclusion. Procedurally, a first reviewer evaluated abstracts for inclusion. If that reviewer decided the article was worthy of inclusion, it was retained. If an article was judged not to meet inclusion criteria, it was reevaluated by a senior reviewer who could reverse the decision. Each exclusion decision was given a coded reason for exclusion.

For the studies included in the initial report, criteria adapted from West et al. 2002 were used to rate the quality of individual studies. The quality rating reflected a cumulative scoring of 25 items in 11 categories: (1) research aim/study question, (2) study population, (3) randomization, (4) blinding, (5) interventions, (6) outcomes, (7) statistical analysis, (8) results, (9) discussion, (10) external validity, and (11) funding/sponsorship. Each item was weighted equally and a score was calculated out of 100%, excluding items not applicable based on study design. In the next step, the scores were collapsed into three categories: poor (0%–59%), fair (60%–74%), and good (75%–100%). Studies rated as poor were excluded from the summary review (see Berkman et al., 2006, for details).

For the updated review, we did not evaluate the quality of newly published individual studies or reevaluate the quality of the evidence base as a whole. We did, however, expand the review in one important way. Clinical consensus agrees that the initial and critical step in the treatment of AN is weight restoration (also called renutrition or refeeding). However, very little empirical evidence exists to evaluate the optimal approach to refeeding. Here, we include weight restoration as one of our target treatments for discussion, and we present findings from the clinical consensus panel recommendations that are available, as well as the few relevant published studies in the area. Consensus panel recommendations are also included for other psychosocial interventions presented in this review.

3 Weight Restoration/Nutritional Rehabilitation

  1. Top of page
  2. Overview of the Disorder
  3. Sources of Information for This Report
  4. Weight Restoration/Nutritional Rehabilitation
  5. Cognitive Behavior Therapy
  6. Family-Based Therapy
  7. Cognitive Analytic Therapy
  8. Summary
  9. References

Restoring healthy eating patterns and healthy weight are the critical first steps in the clinical management of AN (American Psychiatric Association, 2006; Yager & Andersen, 2005). Although this is a common approach, strikingly, this is the aspect of treatment that is least studied to date. This is, in part, due to the logistic difficulties of randomization in inpatient treatment settings, the potential cost of funding studies of inpatient weight restoration in the United States, and the complexities of adequate insurance coverage for the refeeding phase of treatment.

3.1 Consensus Panel Recommendations

American Psychiatric Association. The APA practice guidelines specify eight aims of treatment for AN (Table 3).

Table 3. APA Practice Guidelines for the Treatment of Anorexia Nervosa
  1. a

    Source: Reprinted with permission from APA Practice Guidelines for the Treatment of Patients with Eating Disorders, Third Edition (Copyright © 2006). American Psychiatric Association.

  • Aim 1. Restore the patient to a healthy weight (associated with the return of menses and normal ovulation in female patients, normal sexual drive and hormone levels in male patients, and normal physical and sexual development in children and adolescents).

  • Aim 2. Treat the patient's physical complications.

  • Aim 3. Enhance the patient's motivation to cooperate in the restoration of healthy eating patterns and participate in treatment.

  • Aim 4. Educate the patient regarding healthy nutrition and eating patterns.

  • Aim 5. Help the patient reassess and change core dysfunctional cognitions, attitudes, motives, conflicts, and feelings related to the eating disorder.

  • Aim 6. Treat the patient's associated psychiatric conditions, including deficits in mood and impulse regulation, self-esteem, and behavior.

  • Aim 7. Enlist family support and provide family counseling and therapy where appropriate.

  • Aim 8. Prevent the patient from relapsing.

With reference to nutritional rehabilitation, the APA practice guidelines emphasize the importance of restoring weight, normalizing eating patterns, achieving normal perceptions of hunger and satiety, and correcting biological and psychological sequelae of malnutrition (Golden & Meyer, 2004; Kaye, Gwirtsman, Obarzanek, & George, 1988). According to APA guidelines, inpatient weight restoration is recommended for individuals at 75% of IBW or lower. In addition, APA guidelines emphasize determining targeted weights and working toward expected rates of controlled weight gain (i.e., 2–3 pounds/week for individuals who are in the hospital, 0.5–1 pounds/week for outpatient, and between those two amounts for partial hospitalization or intensive outpatient approaches). The guidelines caution against rapid refeeding, which can lead to fluid retention and a condition known as “refeeding syndrome” (Solomon & Kirby, 1990). Refeeding syndrome is characterized by cardiovascular, neurologic, and hematologic complications due to shifts in phosphate from extracellular to intracellular spaces. This occurs in patients who have total body phosphorus depletion as a result of malnutrition and can occur in response to oral, parenteral, or enteral nutrition (Birmingham, Alothman, & Goldner, 1996; Birmingham, Puddicombe, & Hlynsky, 2004; Solomon & Kirby, 1990). The APA guidelines do not provide direction regarding how best to attain these targeted weight gains.

American Academy of Pediatrics. The practice guidelines for the AAP focus heavily on the role of the pediatrician during the refeeding process, but also provide some guidance as to the pace and approach to refeeding. The AAP states that the pediatrician involved in the treatment of a hospitalized patient with AN should be prepared to provide nutrition via a nasogastric tube or intravenously when necessary. The guidelines also alert physicians to possible metabolic, cardiac, and neurologic complications associated with malnourishment and refeeding, and explicitly warn against refeeding syndrome in severely malnourished patients (Solomon & Kirby, 1990). The guidelines encourage the pediatrician to focus on slow refeeding, possibly with phosphorus supplementation in order to achieve adequate weight gain and avoid refeeding syndrome.

3.2 Evidence Base

One recent inpatient study suggests that the addition of cycle enteral nutrition to usual meals and snacks increases energy intake, improves short-term weight and fat-free mass gains, and is associated with a longer relapse-free period postdischarge (Rigaud, Brondel, Poupard, Talonneau, & Brun, 2007). Although inpatient weight restoration is common, especially in severely malnourished individuals, the evidence does not yet exist to compare this approach to an intensive outpatient or partial hospitalization approach for reasons mentioned earlier; these include logistical issues related to inpatient randomization, and funding and insurance coverage limitations for inpatient weight restoration studies in the United States. Such comparisons are critical, however, given the high relapse rate posthospitalization (Herzog et al., 1999). Presumably, the high posthospitalization relapse rate reflects the fact that the tightly controlled conditions under which supervised weight gain occurs simply cannot generalize to noninstitutional settings. At this time, there are no validated methods for improving generalizability that directly reduce relapse.

One published study compared strict and lenient operant conditioning approaches to refeeding and found that the lenient approach was more economical of nursing time and more acceptable to the patients, but not more beneficial in promoting weight gain (Touyz, Beumont, Glaun, Phillips, & Cowie, 1984). A recent study compared specialist outpatient treatment with general child and adolescent outpatient treatment and with inpatient treatment and found no differences on any biological, eating, or psychological outcome measures. However, those who refused randomization to inpatient treatment, but then continued with outpatient treatment, showed a greater increase in Morgan-Russell average outcome scores after 1 year of treatment (S. G. Gowers et al., 2007).

Refeeding is a challenging and anxiety-provoking part of treatment for the patient with AN. Though the APA and AAP guidelines provide some assistance for the physician who is directing or assisting with the refeeding process, there is less guidance for managing the psychological aspects of treatment during this very difficult time. Studies are desperately needed in order to determine the optimal approach to weight restoration: one that achieves adequate weight gain and addresses the psychological challenges of refeeding in a manner that is acceptable to the patient and family.

3.3 Conclusions

The consensus opinion is that the restoration of healthy eating and resumption of healthy weight are necessary and critical first steps in the treatment of AN. Indeed, most other elements of treatment and recovery are contingent upon achieving these objectives. However, to date, few studies have evaluated refeeding to determine optimal conditions or key individual difference factors that influence or predict successful refeeding. RCTs are needed to establish an evidence base for refeeding paradigms that maximize weight gain and establish healthy eating behavior while also addressing important emotional and family issues that may interfere with meeting these goals.

4 Cognitive Behavior Therapy

  1. Top of page
  2. Overview of the Disorder
  3. Sources of Information for This Report
  4. Weight Restoration/Nutritional Rehabilitation
  5. Cognitive Behavior Therapy
  6. Family-Based Therapy
  7. Cognitive Analytic Therapy
  8. Summary
  9. References

4.1 Consensus Panel Recommendations

APA. The APA recommends a comprehensive treatment plan that evolves from the foundation of a strong therapeutic alliance between patient and provider (American Psychiatric Association, 2006). Awareness of the patient's cultural background and trauma history can be important in establishing these connections. A team approach to treatment is the preferred model of care. The team approach targets not only the patient's eating symptoms and behaviors but also his/her general medical condition and psychiatric status/safety. The treatment team ideally consists of clinicians who can provide nutritional counseling, rehabilitation, and pharmacological interventions, as needed. The APA recommends that family involvement and education be considered on a case-by-case basis.

The APA stipulates four primary goals of treatment to help patients:

  1. Understand and cooperate with their nutritional and physical rehabilitation.

  2. Understand and change behaviors and dysfunctional attitudes related to their AN.

  3. Improve their interpersonal and social functioning.

  4. Address coexisting psychopathology and psychological conflicts that reinforce or maintain their dysfunctional eating behaviors.

The practitioner is advised to develop and express empathy toward the patient, educate the patient about AN, provide positive reinforcement for meeting treatment goals, and help the patient develop his or her own sense of motivation to recover. These elements may be particularly critical in the early stages of treatment of the acutely ill patient, when more formal psychotherapy is often difficult due to high levels of patient negativism and mild cognitive impairment.

The APA emphasizes that all successful treatments are built on a working knowledge of the patient and his/her salient issues in key areas related to psychodynamic conflicts, cognitive development, psychological defenses, family dynamics, and comorbid psychological diagnoses. In addition, the APA states that psychotherapy alone is insufficient to treat the medically compromised patient with AN, and recommends that every patient receives individual psychotherapy after initial weight restoration for a minimum of 1 year.

After weight restoration, the focus of psychotherapy is to help patients understand the roles that cognitive distortions, developmental factors and familial influences, and poor emotion regulation played in their illness. Improving coping skills and developing strategies to avoid or minimize risk of relapse are also important goals during this phase of treatment. The APA makes no specific recommendations about which forms of psychotherapy to pursue, but rather acknowledges that cognitive behavior therapy (CBT) is the most widely studied and substantiated approach to date, despite conflicting opinions about CBT's effectiveness among experienced clinicians. For the chronically ill patient who shows a suboptimal response to psychotherapy, nonverbal therapeutic methods (creative arts, movement therapy, occupational therapy) can be useful.

AAP. The AAP makes no specific recommendations regarding the utility of CBT in the treatment of children with AN (Pediatrics, 2003). Rather the AAP's position statement on the treatment of eating disorders in children emphasizes the pediatrician's role in screening, education, and advocacy.

4.2 Evidence Base

CBT studies generally used a form of therapy specifically tailored to AN to include cognitive and behavioral features associated with maintaining eating pathology. Of the three CBT studies reviewed, one followed inpatient weight restoration and compared CBT to nutritional counseling (Pike, Walsh, Vitousek, Wilson, & Bauer, 2003), while two followed outpatients in the underweight state and compared CBT to interpersonal therapy (IPT), nonspecific supportive clinical management (NCSM) (V. McIntosh et al., 2005) (later renamed Specialist Supportive Clinical Management [SSCM]; V. V. McIntosh et al., 2006), or behavioral therapy (BT) (Channon, De Silva, Hemsley, & Perkins, 1989) (Table 4). Interpersonal therapy for AN derives from IPT previously used for depression (Klerman, Weissman, Rounsaville, & Chevron, 1984) and bulimia nervosa (Fairburn, 1993), and targets one interpersonal problem area; interpersonal disputes, role transitions, grief, or interpersonal deficits. In the McIntosh study (V. McIntosh et al., 2005), SSCM reflected a treatment similar to community-based treatments from a clinician familiar with the treatment of eating disorders; it incorporated elements of sound clinical management and supportive psychotherapy and in this instance was delivered in manualized form.

Table 4. Results From Behavioral Intervention Trials in Adults: Anorexia Nervosa
Source, Treatment, and SettingMajor Outcome MeasuresSignificant Change Over Time Within GroupsSignificant Differences Between Groups at EndpointSignificant Differences Between Groups in Change Over Time
  1. a

    Note: ABW, average body weight; BDI, Beck Depression Inventory; BMI, body mass index; BT, behavioral therapy; CAT, cognitive-analytic therapy; CBT, cognitive behavior therapy; EBT, educational behavioral therapy; EDE, Eating Disorders Examination; EDI, Eating Disorders Inventory (EDI-2, Garner, 1991); FU, follow-up; GAF, Global Assessment of Functioning (DSM-IV); HDRS, Hamilton Depression Rating Scale; IBW, ideal body weight; IPT, interpersonal therapy; MOCI, Maudsley Obsessional Compulsive Index; M-R, Morgan and Russell; NSCM, nonspecific supported clinical management; Psych, psychiatric and psychological; pt, patients; Tx, treatment; vs., versus

Channon et al., 1989

CBT vs. BT vs. “Usual care” control

Outpatient

Eating:

  • EDI

  • M-R scale

Biomarker:

  • BMI

  • M-R scale

Psych:

  • BDI

  • MOCI

  • M-R scale

No statistics reported.

At 6-month FU, CBT associated with better psychosexual functioning than BT and BT was associated with greater improvement in menstrual functioning than CBT.

At 1-year FU, the BT group scored better than the CBT group on preferred weight. CBT and BT combined were associated with greater improvements on nutritional functioning than the control group. The control group showed greater improvements on drive for thinness than the combined CBT and BT groups.

No statistics reported.

V. McIntosh et al., 2005

CBT vs. IPT vs. NSCM

Outpatient

Eating:

  • EDE

  • EDI

Biomarker:

  • BMI

  • Percent body fat

  • Weight

Psych:

  • GAF

  • HDRS

 Compared to IPT, NSCM associated with higher likelihood of “good” global outcome.

NSCM superior to IPT in improving global functioning and eating restraint over 20 weeks.

NSCM superior to CBT in improving global functioning over 20 weeks.

CBT superior to IPT in improving eating restraint over 20 weeks.

Pike et al., 2003

CBT vs. nutritional counseling

Outpatient

Eating:
  • Recovery

  • Relapse

  • Tx failure

  • M-R scale

No statistics reported.Compared to nutrition counseling, CBT associated with lower percentage tx failures, higher percentage “good” outcome, and longer time (weeks) to relapse.No statistics reported.

Dare et al., 2001

CAT vs. focal vs. family vs. “routine” therapy

Outpatient

Eating:

  • M-R scale

  • Recovery

Biomarker:

  • BMI

  • Percent ABW

  • M-R scale

Psych:

  • M-R scale

No statistics reported.At 1-year FU, compared to routine tx, focal and family tx associated with higher weight; also, higher percentage of patients in focal and family tx were recovered or significantly improved (i.e., > 85% IBW, no/few menstrual or BN symptoms).No statistics reported.

Treasure et al., 1995

CAT vs. EBT

Outpatient

Eating:

  • M-R scales

Biomarker:

  • BMI

  • Weight

Psych:

  • M-R scales

  • Self progress scale

No statistics reported.Compared to EBT, CAT associated with higher self-rating of improvement.No statistics reported.

Crisp et al., 1991; and S. Gowers et al., 1994

Inpatient tx vs. outpatient individual and family therapy and dietary counseling vs. group therapy vs. no formal tx

Inpatient and outpatient

Eating:

  • M-R scale

  • Remission

Biomarker:

  • BMI

  • M-R scale

  • Weight

Psych:

  • M-R scale

At 1-year FU, global score and menstruation improved in all 4 groups, nutrition score improved in 3 active tx groups, and mental state improved in outpatient family/diet counseling group.

At 2-year FU, mental state improved in outpatient family/diet counseling; global score, menstruation, and nutrition improved in groups that received outpatient family/diet counseling and no formal tx.

Compared to “no formal tx,” outpatient family/diet counseling associated with higher weight and BMI at 1- and 2-year FU.

Compared to “no formal tx,” weight increased more at 1-year FU in all 3 active groups.

Weight increased more at 2-year FU in outpatient family/diet counseling compared to “no formal tx” group.

Compared to nutritional counseling (which included both nutrition education and food exchanges), CBT significantly reduced relapse risk and increased the likelihood of good outcomes (Pike, Walsh, Vitousek, Wilson, & Bauer, 2003). Notably, good outcomes were more common in those who received antidepressant medication in addition to CBT compared to those who were treated with CBT but did not receive medication. Global outcome ratings were highest in the group receiving SSCM, followed by CBT and then IPT, but SSCM differed significantly from IPT only (V. McIntosh et al., 2005). When compared to a control treatment that consisted of routine outpatient management, CBT and BT were both associated with greater improvements in nutritional functioning but lesser improvements in ratings of drive for thinness (Channon, De Silva, Hemsley, & Perkins, 1989).

4.3 Conclusions

Based on the limited evidence base available for CBT, one can tentatively conclude that CBT reduces relapse risk for adults with AN after weight restoration, but it is not clear whether CBT is more helpful than other approaches in the acutely underweight state. Strong conclusions about the efficacy of CBT for treatment of AN cannot be drawn until these studies are replicated and extended to include adolescent as well as adult patients.

5 Family-Based Therapy

  1. Top of page
  2. Overview of the Disorder
  3. Sources of Information for This Report
  4. Weight Restoration/Nutritional Rehabilitation
  5. Cognitive Behavior Therapy
  6. Family-Based Therapy
  7. Cognitive Analytic Therapy
  8. Summary
  9. References

5.1 Consensus Panel Recommendations

APA. The APA endorses family and couples therapy to address the impact of the illness on the patient's social network (and vice versa) as well as group therapy for patients who are emotionally stable enough to tolerate hearing about and seeing the progress and shortcomings of other group members. The APA guidelines underscore that family therapy is more beneficial than individual therapy for patients who are younger than age 19 years, have been ill for no more than 3 years, and are weight restored. Therefore, family therapy for children and adolescents is strongly endorsed both during acute illness and after weight restoration. Family therapy has several components but begins with helping the parents to develop a consistent approach to refeeding, sympathizing with their situation, and explicitly refuting the belief that they caused the disordered eating. Siblings are often engaged to support the affected sibling. Parents use the therapist as a source of support and consultation to help them determine how best to refeed and weight restore their child.

AAP. The AAP guidelines similarly underscore the importance of the pediatrician collaborating closely with mental health experts to provide the necessary psychological, social, and psychiatric care (Powers, 1996; A. L. Robin, Gilroy, & Dennis, 1998; Yager, 1994). One role of the pediatrician is to help monitor psychotropic medication side effects, such as drowsiness, that can interfere with cognitive function and with treatment engagement. The AAP guidelines note that multidisciplinary teams often find it helpful to divide the treatment, with mental health clinicians providing individual, family, and group therapy. The AAP highlights that family therapy is especially helpful for younger children and adolescents and is imperative for improving long-term prognosis (Eisler et al., 1997; Geist, Heinmaa, Stephens, Davis, & Katzman, 2000; Russell, Szmukler, Dare, & Eisler, 1987). The guidelines acknowledge that optimal gains are achieved via family therapy only after proper nutritional status has been restored because malnourished patients often experience cognitive impairment that interferes with the learning and application of concepts taught in family therapy sessions.

5.2 Evidence Base

The evidence for family-based studies includes two studies that incorporated various forms of family therapy with adults (Crisp et al., 1991; Dare, Eisler, Russell, Treasure, & Dodge, 2001; S. Gowers, Norton, Halek, & Crisp, 1994); five family therapy studies focused exclusively on adolescents (Eisler et al., 2000; Eisler, Simic, Russell, & Dare, 2007; Geist, Heinmaa, Stephens, Davis, & Katzman, 2000; Lock, Agras, Bryson, & Kraemer, 2005; Lock, Couturier, & Agras, 2006; Lock, Le Grange, Agras, & Dare, 2001; A. Robin, Siegel, Koepke, Moye, & Tice, 1994; A. L. Robin, Siegel, & Moye, 1995); and one that combined adolescent and adult patients (Eisler et al., 1997; Russell et al., 1987) (Table 5).

Table 5. Results From Behavioral Intervention Trials in Adolescents Only and Adolescents and Adults Combined: Anorexia Nervosa
Source, Treatment, Setting, and Quality ScoreMajor Outcome Measures

Significant Change

Over Time

Within Groups

Significant Differences Between Groups at EndpointSignificant Differences Between Groups in Change Over Time
  1. a

    Note: ABW, average body weight; AN, anorexia nervosa; BDI, Beck Depression Inventory; BFST, behavioral family systems therapy; BMI, body mass index; BSI, Brief Symptom Inventory; BSQ, Body Shape Questionnaire; CDI, Children's Depression Inventory; CFT, conjoint family therapy; EAT, Eating Attitudes Test; ED, eating disorders; EDE, Eating Disorders Examination; EDI, Eating Disorders Inventory; EOIT, ego-oriented individual therapy; FAD, Family Assessment Device; FAM-III, Family Assessment Measure; FU, follow-up; HoNOSCA, Health of the Nation Outcome Scale for Children and Adolescents; IBC, Interaction Behavior Code; IBW, ideal body weight; MFQ, Mood and Feelings Questionnaire; MOCI, Maudsley Obsessional Compulsive Index; M-R, Morgan and Russell; PARQ, Parent Adolescent Relationship Questionnaire; Psych, psychiatric and psychological; SFT, separated family therapy; SMFQ, Short Mood and Feeling Questionnaire; tx, treatment; vs., versus; YBC-EDS, Yale-Brown-Cornell Eating Disorders Scale

Eisler et al., 2000; and Eisler et al., 2007

CFT vs. SFT

Outpatient

Eating:

  • Bulimic symptoms

  • EAT

  • EDI

Biomarker:

  • Percent ABW

  • BMI

  • Weight

Psych:

  • MOCI

  • SMFQ

  • Depression

  • Obsessionality

No statistics reported.No statistics reported.

CFT superior to SFT in reducing ED-related traits, depression, and obsessionality after 1 year of tx.

At 5-year FU, no differences between SFT and CFT on major outcomes; however, SFT superior to CFT in rate of menstrual functioning return, and in percent average weight gain within subgroup defined as having high levels of “expressed emotion.”

Geist et al., 2000

Family therapy vs. family group psychoeducation

Inpatient

Eating:

  • EDI

Biomarker:

  • Percent IBW

Psych:

  • BSI

  • CDI

  • FAM III

No statistics reported.No differences on any measures.No differences on any measures.

Russell et al., 1987; and Eisler et al., 1997

Family therapy vs. individual therapy

Outpatient

Eating:

  • M-R scales

  • Readmit rate

Biomarker:

  • Percent ABW

  • M-R scales

  • Weight

Psych:

  • M-R scales

No statistics reported.No statistics reported.Among early onset, less chronic AN patients, family therapy superior to individual therapy in improving nutritional status, menstrual and psychosexual function, and weight over 1-year tx; family therapy also more likely associated with a “good” outcome over 1-year tx and 5-year FU.

A. L. Robin et al., 1994; and A. L. Robin et al., 1995

BFST vs. EOIT

Outpatient and inpatient

Eating:

  • EAT

  • EDI

  • Eating conflict

Biomarker:

  • BMI

  • Weight

  • Menstruation

Psych:

  • BDI

  • BSQ

  • PARQ

  • IBC

No statistics reported.No differences on any measures.BFST superior to EOIT in increasing BMI to post-tx and 1-year FU, and in improving mother's positive communication at FU.

Lock et al., 2005; and Lock et al., 2006

Long-term (12 months) vs. short-term (6 months) family therapy

Outpatient

Eating:

  • EDE

  • YBC-EDS

Biomarker:

  • BMI

  • Weight

No differences on any measures.No differences on any measures.

No differences on any measures among those with most severe YBC-EDS symptoms.

At 1 year, longer-term tx associated with better BMI outcome in those with most severe ED symptoms, and with better EDE global outcome in those with nonintact families. An average of 4 years after tx, no differences between groups in BMI or EDE measures.

S. G. Gowers et al., 2007; Byford et al., 2007

Specialist outpatient vs. General child and adolescent mental health service vs. in patient

Outpatient and inpatient

Eating:

  • EDI

  • M-R food intake

Biomarker:

  • BMI

  • Weight

  • Menstruation

Psych:

  • M-R scales

  • FAD

  • MFQ

  • HoNOSCA

No statistics reported.No differences on any measures.No statistics reported, except in subanalysis among those randomized to inpatient: refusing admission and continuing outpatient associated with greater increase in M-R average outcome after 1 year of tx. Treatments did not differ significantly in cost-effectiveness.

Focal therapy is a standardized form of time-limited psychoanalytic psychotherapy in which the therapist takes a nondirective stance and intentionally withholds advice about the eating-related problems or symptoms. Instead, he or she addresses: (a) the conscious and unconscious meanings of the symptoms in terms of the patient's history and of their experience with their family, (b) the effects of the symptom and its influence upon the patient's current relationships, and (c) the manifestation of those influences in the patient's relationship with the therapist in the present and as it controls the patient's desire to get benefit from therapy (a focus on the transference; Dare et al., 2001). Dare et al. 2001 compared focal family therapy to standard family therapy and routine treatment. In this instance, family therapy focused on the child's eating disorder as a problem of family life affecting all family members, helping parents to take a very active role to oppose the anorectic eating habits and eliminating the eating disorder, as far as is possible, from its controlling role in family relationships. Routine treatment involved low contact outpatient management consisting of 30-minute sessions with a trainee psychiatrist who provided specific information about the nature and consequences of AN, supportive encouragement toward a more regular, sustainable, and healthy diet, and regular monitoring of weight and physical status. In this setting, focal family therapy was superior to routine treatment in increasing percentage of adult body weight, restoring menstruation, and decreasing bulimic symptoms; overall clinical improvement was rated as modest (Dare et al., 2001).

A second RCT compared outcomes in adults with AN assigned to one of four treatment options: (1) inpatient treatment, (2) outpatient individual and family therapy, (3) outpatient group therapy, and (4) referral back to family physician. At 1-year follow-up, outpatient therapy involving the family (as well as inpatient and outpatient group therapy) was superior to family physician referral in terms of weight gain, return of menstruation, and various aspects of sexual and social adjustment. At 2-year follow-up, only the outpatient family and physician referral groups were compared, confirming superiority of the individual plus family therapy approach to family physician referral for weight and BMI gain (Crisp et al., 1991; S. Gowers et al., 1994).

Other forms of family-based psychotherapy, including conjoint family therapy (CFT), separated family therapy (SFT), behavioral family systems therapy (BFST), and family psychoeducation, have been investigated in the treatment of adolescents with AN. In CFT the family is treated as a unit, whereas in SFT the parents and the patient are seen separately. BFST combines cognitive restructuring and problem-solving communication training. Eisler and colleagues (Eisler et al., 2000) compared family therapy focusing on parental control of renutrition and found that CFT provided a significant advantage over SFT on eating and mood outcomes, but not on weight outcomes. At 5-year follow-up, there were no differences between the groups on weight, eating, or mood; however, SFT was superior to CFT in promoting return of menstruation. In addition, SFT was superior to CFT in weight gain in the subgroup of participants from families with high levels of maternal expressed emotion (Eisler, Simic, Russell, & Dare, 2007). Robin and colleagues (A. Robin et al., 1994; A. L. Robin et al., 1995) compared BFST to ego-oriented individual therapy, which emphasized building ego strength, adolescent autonomy, and insight into the emotional blocks to eating. In terms of increasing BMI and restoring menstruation, BFST was superior to ego-oriented individual therapy; however, there were no differences between treatments in terms of eating or mood outcomes. Notably, Geist et al. 2000 compared the effects of 4 months of family therapy versus family psychoeducation on outcomes in 25 female adolescents with newly diagnosed restrictive eating disorders. At the end of treatment, the groups achieved similar average levels of IBW (95% vs. 91%) and did not differ on any measures of eating disorder pathology (Geist et al., 2000).

A limited number of studies have addressed concerns of optimal duration and timing of family therapy. Adolescents randomized to short (10 sessions over 6 months) versus long (20 sessions over 12 months) family therapy employing a manual-based model of initial parental control of refeeding did not differ on eating, psychiatric, or biomarker outcomes (Lock et al., 2005; Lock et al., 2001). However, longer-term therapy was more effective for those with either nonintact families or those with more severe eating-related obsessions. At 4-year follow-up, there were no differences between the short versus long family therapy on outcomes such as BMI and global functioning assessed with the Eating Disorders Examination (Lock, Couturier, & Agras, 2006). Finally, family therapy was more effective for younger patients with earlier onset of AN than for older patients with a more chronic course (Eisler et al., 1997; Russell, Szmukler, Dare, & Eisler, 1987).

5.3 Conclusions

Overall, family therapy focusing on parental control of renutrition is efficacious in treating younger patients with AN, especially those treated in the earlier stages of their illness. Although few differences were observed when comparing different models of family therapy, each approach led to clinically meaningful weight gain and psychological improvement. Moreover, two studies produced results suggesting that family therapy was superior to individual therapy for adolescent patients with shorter duration of illness. In contrast, there is no evidence supporting family therapy (as currently practiced) as an effective treatment for adults with AN and a comparatively long duration of illness.

6 Cognitive Analytic Therapy

  1. Top of page
  2. Overview of the Disorder
  3. Sources of Information for This Report
  4. Weight Restoration/Nutritional Rehabilitation
  5. Cognitive Behavior Therapy
  6. Family-Based Therapy
  7. Cognitive Analytic Therapy
  8. Summary
  9. References

Cognitive analytic therapy (CAT) is a treatment that borrows from both psychodynamic and behavioral approaches, combining elements of cognitive therapy and brief, focused, psychodynamic psychotherapy (Treasure et al., 1995). CAT assists patients in developing a formal multifaceted conceptualization (in diagram form) of anorexia in their experience of themselves and their early and current relationships, and helps them to use this insight to manage their feelings and relationships rather than rely on AN to function in this capacity.

6.1 Consensus Panel Recommendations

Neither the APA nor the AAP make specific recommendations regarding the use of CAT in adult or adolescent patients with AN.

6.2 Evidence Base

Two studies using CAT failed to find any advantage of CAT over educational behavioral therapy or focal family therapy in eating, mood, or weight outcomes (Dare et al., 2001; Treasure et al., 1995) (Table 4). Dare and colleagues 2001 found CAT to be equivalent to focal family therapy in increasing percentage of adult body weight, restoring menstruation, and decreasing bulimic symptoms; overall clinical improvement was modest. In a small pilot study of adult patients with AN, weight and Morgan-Russell outcomes (nutritional, menstrual, mental state, psychosexual functioning, social functioning) were evaluated in a group assigned to CAT versus a group assigned to educational behavioral treatment in which patients monitored their daily intake using diaries. At the end of the study, the CAT group reported higher self-ratings of improvement compared to the group assigned to educational behavioral treatment (Treasure et al., 1995).

6.3 Conclusions

Compared with other forms of psychotherapy used in the treatment of AN, CAT has received less attention and systematic evaluation. Limited findings suggest that patients who undergo CAT achieve similar gains (weight restoration, clinical improvement) compared to those undergoing family therapy; however, the evidence base is insufficient at this time to conclude that CAT is an efficacious treatment strategy for adults or adolescents with AN.

7 Summary

  1. Top of page
  2. Overview of the Disorder
  3. Sources of Information for This Report
  4. Weight Restoration/Nutritional Rehabilitation
  5. Cognitive Behavior Therapy
  6. Family-Based Therapy
  7. Cognitive Analytic Therapy
  8. Summary
  9. References

Anorexia nervosa is a pernicious illness and successful treatment requires involvement of a multidisciplinary team of practitioners with expertise in the management of medical, psychological, and family issues that impact the course of recovery (American Psychiatric Association, 2006). Refeeding and weight restoration are pivotal first steps in treatment; individuals at 75% of IBW or lower usually require inpatient hospitalization to initially address these crucial issues, although many other factors influence level of care decisions. Hospitalization can be very costly, both in terms of financial and emotional stress incurred by the patient and family. Therefore, when facilities are available, hospitalization can be followed by various levels of step-down care that allow for increasing autonomy and exposure to real-life eating and emotional situations. The APA and AAP provide practice guidelines for physicians treating patients with AN. Despite its importance, no RCTs for AN have established the optimal approach to inpatient weight restoration and postdischarge weight gain maintenance. Standards are lacking regarding the appropriateness of the recommendation for hospitalization at 75% IBW, methods and milestones of renutrition, and transitions from inpatient treatment to less structured environments. Further studies are clearly needed to address these important aspects of treatment toward the goal of maximizing treatment gains and minimizing financial and psychological burdens on patients and their families.

Various forms of psychotherapy have been used in the treatment of AN, and a select few have been evaluated in the context of an RCT. These include CBT, family therapy, and CAT delivered in both hospital and outpatient settings. At the time of our 2006 review, the evidence base for psychotherapy treatment efficacy in adults was weak and for treatment efficacy in adolescents was modest (Berkman et al., 2006).

For adults with AN, tentative evidence suggests that CBT reduces relapse risk after weight has been restored, especially among those who also are treated with antidepressant medication; however, the extent to which CBT is helpful in those who are acutely underweight remains unclear. When provided as outpatient treatment for underweight patients, CBT was similar to other forms of psychotherapy (e.g., IPT or SSCM) in improving weight, mood, or eating behavior. None of the CBT findings have been replicated, and no CBT-focused RCTs have been conducted in younger patients.

Efficacy of family therapy and CAT, as they are currently practiced, has yet to be determined. For younger patients, family therapy focusing on parental control of refeeding results in clinically meaningful weight gain and psychological improvement and may be superior to individual therapy for adolescent patients with shorter duration of illness. For adults, family therapy may be more effective than medical management by a family physician. Generally, there is a need for studies that include the adult patient's family of insertion (spouse and offspring of the patient) and that incorporate life span-appropriate and family constellation modifications to the therapy model. Until then, the potential efficacy of family therapy for adults cannot be ruled out. Likewise, more studies are needed to establish the efficacy of CAT and to compare CAT to other cognitive and behavioral treatment modalities.

7.1 Critiquing the Literature

Overall, the literature on psychotherapy treatments for AN is lacking in several key areas (Berkman et al., 2006).

  1. Generally, studies have been underpowered. Samples have been too small to examine important questions about differential efficacy as a function of race/ethnicity, sex, or age; or worse yet, subgroup analyses exploring difference based on these factors have been performed on outcome variables in the absence of a priori hypotheses, possibly resulting in inflated error rates of discovery and misleading conclusions.

  2. Studies have also been ill-conceived with respect to participant drop out (attrition), which has been quite high (up to 43%) and often unbalanced across treatment groups. Some studies only analyzed outcomes among participants who actually completed the study, ignoring potentially important information gained through intent-to-treat analyses that incorporate data obtained from participants before they drop out of the trial. Beyond these most basic issues, the overall quality of the literature has suffered due to inattention to study design details and inadequate follow-up to assess long-term outcomes (such as osteoporosis, dental health, cardiovascular health, etc.). Addressing these problems will require researchers and clinicians to (a) identify means of increasing motivation for treatment and treatment retention for individuals with AN who enroll in clinical studies; and (b) increase scientific rigor by adhering to stricter methods of randomization, measurement, and statistical design.

  3. Consensus definitions for stage of illness, remission, recovery, and relapse do not exist. As a result, it is difficult to interpret results within and across studies. Standardized definitions of these terms for AN along with standardized methods to measure them will facilitate cross-study comparisons and meta-analytic approaches. Ultimately, these improvements will enable researchers and clinicians to interpret and appreciate statistically significant and clinically meaningful differences in treatment outcomes.

  4. Males and persons of racial/ethnic minorities are grossly underrepresented in clinical trials involving patients with AN. As a result, we have a poor understanding of the prevalence of AN in these important subgroups and have no knowledge of their unique treatment needs or responses to treatment. Accumulating this information must become a priority in future RCTs; this will not only improve recruitment and retention of participants in treatment trials but also advance our ability to tailor treatment strategies to meet the needs of these diverse individuals.

  5. Clinical trials for AN do not adequately reflect the type of treatment typically available and delivered in the community and, thus, are unable to address the key challenges facing many clinicians who treat patients with this disorder. Often, insurance coverage limitations present a major stumbling block to diversifying treatment studies into the community. Working in partnership with insurance companies (in order to increase access to trials given the current reimbursement milieu) may be critical to success and to transitioning from efficacy to effectiveness studies.

  6. Studies to date have not been forthcoming about adverse events, specifically, the degree of medical compromise experienced by study participants or strategies developed to monitor for potential harm. Given the high attrition from AN trials, behavioral interventions should pay greater attention to both physical and psychological harms associated with interventions that may impact the decision to continue treatment. All studies should report adverse events associated with interventions and whether adverse events differ between underweight and weight-restored patients.

7.2 Future Research Needs

Discovering new interventions that target the core biological and psychological features of AN, address adverse medical sequelae such as osteoporosis, and enhance motivation and retention in medication trials are critically needed steps. Research on innovative medications and behavioral treatments are warranted. These innovative approaches can include adapting interventions that are efficacious for other disorders as well as identifying new interventions for increasing motivation, acceptability, and retention in treatment. In addition, further dismantling of complex therapies such as CBT to determine the active therapeutic components is also warranted.

Application of new information technologies has shown promise in the treatment of eating disorders. Preliminary studies have found good treatment acceptability in the use of the Internet and text messaging for bulimia nervosa and binge eating disorder (Bauer, Hagel, Okon, Meermann, & Kordy, 2006; Bauer, Percevic, Okon, Meermann, & Kordy, 2003; Shapiro et al., 2007; Shapiro et al., 2010). Adequately powered clinical trials that include the use of e-mail, the Internet, personal digital assistants, text messaging, and other technological advances to enhance treatment will add to future treatment development and should be the next steps for testing technological approaches. Given the high rates of shame, denial, and interpersonal deficits experienced by patients with AN, these approaches (which provide a higher degree of privacy than is afforded by direct patient–therapist contact in a public health-care setting) may be particularly helpful. These approaches also provide improved access to outpatient treatment for patients who live in remote/rural areas, which are likely underserved by psychotherapists and doctors with expertise in AN. Finally, these approaches may promote treatment retention and relapse prevention by increasing the frequency of patient–provider contact.

In sum, our working knowledge of effective psychotherapy treatments for AN is limited on many fronts. Larger, multisite RCTs that include more diverse patient samples, employ more rigorous methodological and analytical approaches, and address the core pathology and long-term medical and psychological sequelae of AN are needed. Ultimately, knowledge gained from future studies will clarify the role of psychotherapy within the multidisciplinary treatment framework as well as improve delivery of treatments tailored to meet the specific needs of individual patients and their families.

End Notes
  1. 1

    Acknowledgments: This research was supported by the contract 290-02-0016 from the Agency for Healthcare Research and Quality. We also thank Xiaofei Mo, MD, and Anne Cercone, BA, for their assistance with the literature review.

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  1. Top of page
  2. Overview of the Disorder
  3. Sources of Information for This Report
  4. Weight Restoration/Nutritional Rehabilitation
  5. Cognitive Behavior Therapy
  6. Family-Based Therapy
  7. Cognitive Analytic Therapy
  8. Summary
  9. References
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