Other psychological management strategies for anorexia nervosa

Author/s
Anastasia Saoulidi, Lucy Serpell
Citation
Focus Issue 6: Eating disorders
CEPiP.2024.1.201-206
Abstract

In addition to having the highest rate of mortality among all psychiatric disorders and causing profound negative effects on quality of life, anorexia nervosa (AN) remains challenging to address. Apart from cognitive behavioural therapy and family therapy (FT), the current National Institute for Health and Care Excellence guidelines recommend several types of psychological therapy as first-line treatment for AN, including the Maudsley Model of Anorexia Nervosa Treatment for Adults, specialist supportive clinical management, and focal psychodynamic therapy for adults and adolescent-focused psychotherapy for young people. This article aims to describe these treatments and the existing evidence base. Research suggests that all recommended treatments for AN are equally effective at addressing core eating disorder psychopathology and increasing body mass index (BMI) in adults, while FT appears to be more effective at increasing BMI in young people. However, the evidence base remains very limited, and relapse rates can range from 9% to 52%. Barriers to conducting trials of interventions for AN include broader factors, such as lack of statistical power due to recruitment challenges, and illness-specific factors, such as patient resistance to change, cognitive rigidity and avoidance. Non-specific therapy-related factors, particularly therapeutic alliance, might play an important role in overall treatment outcomes. More longitudinal evidence and research into the effects of comorbidities is needed to draw stronger conclusions regarding the effectiveness of psychological management strategies for AN.

Keywords: anorexia nervosa, evidence-based treatments, first-line treatments, NICE guidelines

Cite as: Cutting Edge Psychiatry in Practice 2025, 6(1):201-206; https://doi.org/10.65031/nbyb4741

References

  1. World Health Organisation (WHO). ICD-11: International Classification of Diseases 11th Revision [Online] 2022. Accessed 01 October 2023. Available from: https://icd.who.int.      
  2. van Eeden AE, van Hoeken D, Hoek HW. Incidence, prevalence and mortality of anorexia nervosa and bulimia nervosa. Current Opinion in Psychiatry. 2021;34(6):515. https://doi.org/10.1097/yco.0000000000000739
  3. Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders: a meta-analysis of 36 studies. Archives of General Psychiatry. 2011;68(7):724-31. https://doi.org/10.1001/archgenpsychiatry.2011.74
  4. Khalsa SS, Portnoff LC, McCurdy-McKinnon D, Feusner JD. What happens after treatment? A systematic review of relapse, remission, and recovery in anorexia nervosa. Journal of Eating Disorders. 2017;5(1):1-12. https://doi.org/10.1186/s40337-017-0145-3
  5. Ali K, Farrer L, Fassnacht DB, Gulliver A, Bauer S, Griffiths KM. Perceived barriers and facilitators towards help‐seeking for eating disorders: a systematic review. International Journal of Eating Disorders. 2017;50(1):9-21. https://doi.org/10.1002/eat.22598
  6. Cachelin FM, Striegel‐Moore RH. Help seeking and barriers to treatment in a community sample of Mexican American and European American women with eating disorders. International Journal of Eating Disorders. 2006;39(2):154-61. https://doi.org/10.1002/eat.20213
  7. National Institute for Health and Care Excellence (NICE). Eating disorders: recognition and treatment. NICE guideline [NG69] 2017. Updated 16 December 2020. Accessed 10 October 2023. Available from: https://www.nice.org.uk/guidance/ng69/chapter/ Recommendations#identification-and-assessment. https://doi.org/10.24292/01.mf.0120.14
  8. Schmidt U, Startup H, Treasure J. A Cognitive-Interpersonal Therapy Workbook for Treating Anorexia Nervosa: The Maudsley Model. Abingdon, Oxon. Routledge (2019). https://doi.org/10.4324/9781315728483
  9. Schmidt U, Treasure J. Anorexia nervosa: Valued and visible. A cognitive‐interpersonal maintenance model and its implications for research and practice. British Journal of Clinical Psychology. 2006;45(3):343-66. https://doi.org/10.1348/014466505x53902
  10. Treasure J, Schmidt U. The cognitive-interpersonal maintenance model of anorexia nervosa revisited: a summary of the evidence for cognitive, socio-emotional and interpersonal predisposing and perpetuating factors. Journal of Eating Disorders. 2013;1:1-10. https://doi.org/10.1186/2050-2974-1-13
  11. Startup H, Franklin-Smith M, Barber W, Gilbert N, Brown Y, Glennon D, et al. The Maudsley Anorexia Nervosa Treatment for Adults (MANTRA): a feasibility case series of an integrated group based approach. Journal of Eating Disorders. 2021;9(1):70. https://doi.org/10.21203/rs.3.rs-231319/v1
  12. Jordan J, McIntosh VV, Bulik CM. Specialist Supportive Clinical Management for anorexia nervosa: what it is (and what it is not). Australasian Psychiatry. 2020;28(2):156-9. https://doi.org/10.1177/1039856219875024
  13. McIntosh VV, Jordan J, Carter FA, Luty SE, McKenzie JM, Bulik CM, et al. Three psychotherapies for anorexia nervosa: a randomized, controlled trial. American Journal of Psychiatry. 2005;162(4):741-7. https://doi.org/10.1176/appi.ajp.162.4.741
  14. McIntosh VV, Jordan J, Luty SE, Carter FA, McKenzie JM, Bulik CM, et al. Specialist supportive clinical management for anorexia nervosa. International Journal of Eating Disorders. 2006;39(8):625-32. https://doi.org/10.1002/eat.20297
  15. Touyz S, Le Grange D, Lacey H, Hay P, Smith R, Maguire S, et al. Treating severe and enduring anorexia nervosa: a randomized controlled trial. Psychological Medicine. 2013;43(12):2501-11. https://doi.org/10.1017/s0033291713000949
  16. Friederich H-C, Wild B, Zipfel S, Schauenburg H, Herzog W. Anorexia Nervosa: Focal Psychodynamic Psychotherapy. Toronto, ON. Hogrefe Publishing (2018). https://doi.org/10.1027/00554-000
  17. Hay PJ, Claudino AM, Touyz S, Abd Elbaky G. Individual psychological therapy in the outpatient treatment of adults with anorexia nervosa. Cochrane Database of Systematic Reviews. 2015(7). https://doi.org/10.1002/14651858.cd003909.pub2
  18. Wild B, Friederich H-C, Gross G, Teufel M, Herzog W, Giel KE, et al. The ANTOP study: focal psychodynamic psychotherapy, cognitivebehavioural therapy, and treatment-as-usual in outpatients with anorexia nervosa-a randomized controlled trial. Trials. 2009;10(1):1-7. https://doi.org/10.1186/1745-6215-10-23
  19. Robin AL, Siegel PT, Koepke T, Moye AW, Tice S. Family therapy versus individual therapy for adolescent females with anorexia nervosa. Journal of Developmental and Behavioral Pediatrics. 1994;15(2):111-6. https://doi.org/10.1097/00004703-199404000-00008
  20. Fitzpatrick KK, Moye A, Hoste R, Lock J, Le Grange D. Adolescent focused psychotherapy for adolescents with anorexia nervosa. Journal of Contemporary Psychotherapy. 2010;40:31-9. https://doi.org/10.1007/s10879-009-9123-7
  21. Steinhausen H-C. The outcome of anorexia nervosa in the 20th century. American Journal of Psychiatry. 2002;159(8):1284-93. https://doi.org/10.1176/appi.ajp.159.8.1284
  22. Byrne S, Wade T, Hay P, Touyz S, Fairburn C, Treasure J, et al. A randomised controlled trial of three psychological treatments for anorexia nervosa. Psychological Medicine. 2017;47(16):2823-33. https://doi.org/10.1017/s0033291717001349
  23. Schmidt U, Magill N, Renwick B, Keyes A, Kenyon M, Dejong H, et al. The Maudsley Outpatient Study of Treatments for Anorexia Nervosa and Related Conditions (MOSAIC): comparison of the Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) with specialist supportive clinical management (SSCM) in outpatients with broadly defined anorexia nervosa: a randomized controlled trial. Journal of Consulting and Clinical Psychology. 2015;83(4):796. https://doi.org/10.1037/ccp0000019.supp
  24. Zipfel S, Wild B, Gro. G, Friederich H-C, Teufel M, Schellberg D, et al. Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in outpatients with anorexia nervosa (ANTOP study): randomised controlled trial. The Lancet. 2014;383(9912):127-37. https://doi.org/10.1016/s0140-6736(13)61746-8
  25. Herzog W, Wild B, Giel KE, Junne F, Friederich H-C, Resmark G, et al. Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in female outpatients with anorexia nervosa (ANTOP study): 5-year follow-up of a randomised controlled trial in Germany. The Lancet Psychiatry. 2022;9(4):280-90. https://doi.org/10.1016/s2215-0366(22)00028-1
  26. Schmidt U, Ryan EG, Bartholdy S, Renwick B, Keyes A, O'Hara C, et al. Two‐year follow‐up of the MOSAIC trial: a multicenter randomized controlled trial comparing two psychological treatments in adult outpatients with broadly defined anorexia nervosa. International Journal of Eating Disorders. 2016;49(8):793-800. https://doi.org/10.1002/eat.22523
  27. Wittek T, Zeiler M, Truttmann S, Philipp J, Kahlenberg L, Schneider A, et al. The Maudsley model of anorexia nervosa treatment for adolescents and emerging adults: a multi‐centre cohort study. European Eating Disorders Review. 2023. https://doi.org/10.1002/erv.2996
  28. Robin AL, Siegel PT, Moye AW, Gilroy M, Dennis AB, Sikand A. A controlled comparison of family versus individual therapy for adolescents with anorexia nervosa. Journal of the American Academy of Child and Adolescent Psychiatry. 1999;38(12):1482-9. https://doi.org/10.1097/00004583-199912000-00008
  29. Lock J, Le Grange D, Agras WS, Moye A, Bryson SW, Jo B. Randomized clinical trial comparing family-based treatment with adolescentfocused individual therapy for adolescents with anorexia nervosa. Archives of General Psychiatry. 2010;67(10):1025-32. https://doi.org/10.1001/archgenpsychiatry.2010.128
  30. Le Grange D, Lock J, Accurso EC, Agras WS, Darcy A, Forsberg S, et al. Relapse from remission at two-to four-year follow-up in two treatments for adolescent anorexia nervosa. Journal of the American Academy of Child and Adolescent Psychiatry. 2014;53(11):1162-7. https://doi.org/10.1016/j.jaac.2014.07.014
  31. Gowers SG, Clark A, Roberts C, Griffiths A, Edwards V, Bryan C, et al. Clinical effectiveness of treatments for anorexia nervosa in adolescents: randomised controlled trial. The British Journal of Psychiatry. 2007;191(5):427-35. https://doi.org/10.1192/bjp.bp.107.036764
  32. Roberts AH, Kewman DG, Mercier L, Hovell M. The power of nonspecific effects in healing: implications for psychosocial and biological treatments. Clinical Psychology Review. 1993;13(5):375-91. https://doi.org/10.1016/0272-7358(93)90010-j
  33. Zainal KA, Renwick B, Keyes A, Lose A, Kenyon M, DeJong H, et al. Process evaluation of the MOSAIC trial: treatment experience of two psychological therapies for out-patient treatment of Anorexia Nervosa. Journal of Eating Disorders. 2016;4:1-12. https://doi.org/10.1186/s40337-016-0091-5
  34. Serpell L, Treasure J, Teasdale J, Sullivan V. Anorexia nervosa: friend or foe? International Journal of Eating Disorders. 1999;25(2):177-86. https://doi.org/10.1002/(sici)1098-108x(199903)25:2<177::aid-eat7>3.3.co;2-4
  35. Guarda AS. Treatment of anorexia nervosa: insights and obstacles. Physiology and Behavior. 2008;94(1):113-20. https://doi.org/10.1016/j.physbeh.2007.11.020
  36. Watson H, Bulik C. Update on the treatment of anorexia nervosa: review of clinical trials, practice guidelines and emerging interventions. Psychological Medicine. 2013;43(12):2477-500. https://doi.org/10.1017/s0033291712002620
  37. Bulik CM, Berkman ND, Brownley KA, Sedway JA, Lohr KN. Anorexia nervosa treatment: a systematic review of randomized controlled trials. International Journal of Eating Disorders. 2007;40(4):310-20. https://doi.org/10.1002/eat.20367
  38. Carter J, Blackmore E, Sutandar-Pinnock K, Woodside D. Relapse in anorexia nervosa: a survival analysis. Psychological Medicine. 2004;34(4):671-9. https://doi.org/10.1017/s0033291703001168