A controlled trial of cognitive-behavioural and behavioural treatment of anorexia nervosa

This study was undertaken to investigate whether a cognitive-behavioural treatment procedure was superior to a standard behavioural treatment, in the outpatient therapy of patients with anorexia nervosa. The two treatments were also compared with a control treatment procedure consisting of routine outpatient management. Each group consisted of eight subjects. All the groups showed some improvement, but the findings did not provide support for the prediction that cognitive-behavioural treatment, designed specifically to manipulate both attitudes and behaviour, was superior to the other types of treatment. The implications of the findings are considered.     

Developing a model of the treatment for eating disorder: Using neuroscience research to examine the how rather than the what of change

Treatments for eating disorders, in particular for people with anorexia nervosa, have often been adaptations of therapies designed for other conditions. Indeed, there is a move advocating the use of a transdiagnostic treatment approach in which general module based treatments are mixed together as needed rather than using a specific anorexia nervosa targeted strategy. The outcome of treatment is relatively poor, especially for those who for some reason do not have the benefit of an expert form of early intervention for anorexia nervosa. Technological advances in the neurosciences and genetics have radically altered how eating disorders and in particular anorexia nervosa have been conceptualised. In this paper we describe evidence that suggests that key aspects of the social information processing network both the cognitive and affective elements may be anomalous in people with anorexia nervosa. This has implications for models of treatment which can be tailored more directly to these causal and or maintaining factors. We describe the Maudsley method of working with adults with anorexia nervosa which has integrated these elements. This treatment approach includes working with the individual to develop a more flexible and holistic cognitive style with greater emotional intelligence. This is supplemented with work with the families to interrupt interactions that either accommodate to or aggravate the symptoms. Thus we are now in the position to understand and work to change how people with anorexia nervosa think and behave rather than focusing on what people think and say they do. Our prediction is that treatments that focus more directly on aetiology such as the intrapersonal and interpersonal maintaining factors will improve outcome.     

Thoughts about eating, weight and shape in anorexia nervosa and bulimia nervosa.

Concurrent verbalisation and a self-report questionnaire were used to investigate self-statements in patients with anorexia nervosa, patients with bulimia nervosa, two groups of dieters and non-dieting controls. Thoughts were collected while subjects performed three behavioural tasks, looking at themselves in a full-length mirror, weighing themselves and eating a chocolate covered mint. Both groups of patients had more negative thoughts related to eating, weight and shape than those in the three control groups. In addition, patients with anorexia nervosa showed a greater concern with eating while patients with bulimia nervosa showed a greater concern with weight and appearance. Differences were found between the patients and non-dieting controls using both methods but the self-report questionnaire was less sensitive than concurrent verbalisation to differences between the patients and dieters. Implications of the findings for cognitive-behavioural treatments of the two disorders are discussed.     

Use of dialectical psychotherapy in treating bulimarexic disorders: A case study

A variety of therapeutic approaches have been used in the treatment of anorexia nervosa and bulimia with varying degrees of success. This paper describes the treatment of a bulimarexic patient by co-therapists, using a dialectical approach.Appreciation is extended to Betty Hoffman for her editorial assistance.     

Nature against nurture: calcification in the right thalamus in a young man with anorexia nervosa and obsessive-compulsive personality disorder

This report describes the case of a young man with a large calcification in the right thalamus that was first diagnosed at 9 years of age. Case history reveals specific eating rituals and other obsessive-compulsive personality traits during the patient's childhood and adolescence, fulfilling diagnostic criteria of obsessive-compulsive personality disorder. After a critical life event the patient develops anorexia nervosa. We suggest that our case and further literature provide evidence for an involvement of specific thalamic structures, such as the dorsomedial nucleus, in the development of anorexia nervosa. Furthermore, the treatment of the patient by a combined psychotherapeutic and pharmacotherapeutic approach is described. We focus on the beneficial effect of the atypical antipsychotic olanzapine, which can induce weight gain by an increase of leptin levels.     

The empirical and theoretical base of family therapy and multiple family day therapy for adolescent anorexia nervosa

There is growing empirical evidence that family therapy is an effective treatment for anorexia nervosa, particularly in adolescence. This is in spite of the fact that the theoretical model from which most of the empirically based treatments are derived appears flawed. This paper provides a brief overview of the research evidence from treatment studies and studies of family functioning. It suggests that the main limitation of earlier theoretical models is their focus on aetiology rather than on an understanding of how families become organized around a potentially life-threatening problem. An alternative conceptual model is presented, and its application to family therapy and multiple-family therapy for adolescent anorexia nervosa is described. The treatment approach focuses on enhancing the families' own adaptive mechanism and mobilizing family strengths.     

Competence to make treatment decisions in anorexia nervosa: thinking processes and values

This paper explores the ethical and conceptual implications of the findings from an empirical study of decision-making capacity in anorexia nervosa. In the study, ten female patients aged 13 to 21 years with a diagnosis of anorexia nervosa, and eight sets of parents, took part in semi-structured interviews. The purpose of the interviews was to identify aspects of thinking that might be relevant to the issue of competence to refuse treatment. All the patient participants were also tested using the MacCAT-T test of competence. This is a formalised, structured interviewer-administered test of competence, which is a widely accepted clinical tool for determining capacity. The young women also completed five brief self-administered questionnaires to assess their levels of psychopathology.The issues identified from the interviews are described under two headings: difficulties with thought processing, and changes in values. The results suggest that competence to refuse treatment may be compromised in people with anorexia nervosa in ways that are not captured by traditional legal approaches or current standardised tests of competence.     

Action monitoring and perfectionism in anorexia nervosa

To study action monitoring in anorexia nervosa, behavioral and EEG measures were obtained in underweight anorexia nervosa patients (n=17) and matched healthy controls (n=19) while performing a speeded choice-reaction task. Our main measures of interest were questionnaire outcomes, reaction times, error rates, and the error-related negativity ERP component. Questionnaire and behavioral results indicated increased perfectionism in patients with anorexia nervosa. In line with their perfectionism and controlled response style patients made significantly less errors than controls. However, when controlling for this difference in error rates, the EEG results demonstrated a reduced error-related negativity in the patient group. These seemingly contradictory outcomes of improved performance and reduced error monitoring are discussed in relation with indications of anterior cingulate cortex hypoactivity in anorexia nervosa patients.     

Is manualized family‐based treatment for adolescent anorexia nervosa acceptable to patients? Patient satisfaction at the end of treatment

Patient satisfaction with treatment sheds light on the acceptability, disseminability and usefulness of treatments. This study aimed to assess the perspectives of families who completed treatment using a manual-driven family-based treatment for anorexia nervosa. We hypothesized that overall, manualized treatment would be viewed as acceptable and helpful, but that none the less, a proportion of patients would identify a wish for other types or additional therapy. A total of thirty-four families participated in the survey. Results suggest that patients and families viewed the treatment as highly effective and acceptable. However, approximately a quarter suggested that individual therapy, more family therapy, and focusing on other issues besides anorexia nervosa would improve treatment. These data suggest that a manual-driven family-based treatment for adolescents with anorexia nervosa is acceptable to adolescents and their parents, though modifications to include additional therapy and individual therapy might be considered in some cases.     

Inside the experience of anorexia nervosa: A narrative thematic analysis

Aim: This study considers the question of whether inpatient admission for anorexia nervosa was a therapeutic experience for two women with chronic anorexia nervosa. The question of whether inpatient admission for anorexia nervosa can be therapeutic is not answerable through existing research evidence. Method: The women were interviewed about their experience of having anorexia, its impact on their lives and the treatment they received. The interviews involved learning about the women's experiences by listening to their stories rather than asking them direct questions about what has been therapeutic about their treatment. Analysis: Their narratives were used to develop understanding grounded in experience and were analysed using a narrative thematic analysis. Ideas, themes and connections were noted but not coded as found in some forms of thematic analysis. Discussion: Consideration is given to the therapeutic qualities of the treatments the women received and the place of therapeutic inpatient admission. The central theme of this research was ‘relationships’ which indicates the use of therapeutic approaches that emphasise the importance of the therapeutic relationship in the treatment of chronic anorexia nervosa. It is suggested that psychodynamic and attachment theories should be used to inform overall treatment models. Some important issues for service provision and areas for further research are identified.     

Multiple family therapy for anorexia nervosa: concepts, experiences and results

Multiple family therapy (MFT) is an increasingly popular treatment approach for adolescents suffering from anorexia nervosa and their families. This paper describes the ingredients and different phases of this treatment, and outlines its indications and contra‐indications. Relationship patterns in families containing anorectic teenagers are examined, with a special emphasis on identifying areas for change in family relationships. Results with regard to the overall acceptability of the approach are presented.     

A Case Series of Family-Based Therapy for Weight Restoration in Young Adults with Anorexia Nervosa

This case series aims to examine the preliminary efficacy, acceptability and feasibility of Family-Based Treatment to promote weight restoration in young adults with anorexia nervosa. Four young adults with sub/threshold anorexia nervosa were provided 11–20 sessions of Family-Based Treatment for young adults with pre-, post- and follow-up assessments. At post- and follow-up, 3/4 participants were in the normal weight range, 3/4 were in the non-clinical range on the Eating Disorders Examination and reported being not/mildly depressed. At post-treatment, 2/4 were in the good psychosocial functioning range and by follow-up, 3/4 were in this range. These results suggest that Family-Based Treatment for young adults with anorexia nervosa is a promising treatment.     

Body images of patients with anorexia nervosa, bulimia nervosa and female control subjects: a comparison with male ideals of female attractiveness

Body images of female patients with anorexia nervosa and bulimia nervosa were assessed against females without eating disorders and compared with male ideals of female attractiveness. A computer program was applied to examine body images of 62 patients with anorexia nervosa, 45 patients with bulimia nervosa, and 40 female and 39 male control subjects. Body size overestimation was most distinct in the two patient groups. Self-ideal discrepancy was highest in bulimia nervosa. Estimation of the society's ideal female body in all three female groups did not differ from men's perception of the most attractive female body. Congruence of ideals of female attractiveness in patients, female, and male control subjects and described differences between patients and female controls support the theory that body image disturbance is a problem of processing self-referential information regarding body image rather than a problem of processing body image related information per se.     

Ambulante manualisierte Verhaltenstherapie bei Anorexia nervosa

Anorexia nervosa is a serious illness leading to high morbidity and mortality. Its treatment poses a particular challenge to psychotherapists offering outpatient treatment. Often therapists follow or work according to a treatment manual. Supervision in the treatment of anorexia nervosa patients intends to promote quality assurance as well as to foster therapists’ mental hygiene. It offers the opportunity to collect plenty of practical experiences. Some of these will be presented here to provide suggestions and support to therapists working with anorexia nervosa patients. Certain treatment modules of cognitive-behavioral therapy (CBT) such as motivation, eating behavior, case formulation and relapse prevention will be considered. Regarding the therapist-patient relationship ambivalent relation shaping and motivational interviewing will be targeted.     

Predisposition factors in anorexia nervosa.

Since its first recognition, a number of researchers have endeavored to link anorexia nervosa to underlying pathology. For example, in the past, attempts were made to associate anorexia with such psychiatric disturbances as schizophrenia, anxiety disorders, and obsessive-compulsive and antisocial personality disorders. Most recent efforts have focused on the possible link between anorexia nervosa and affective disorders. This article reviews the literature concerned with investigating psychiatric disturbances and genetic variables hypothesized as predisposing factors in the etiology of anorexia nervosa. Particular emphasis is given to research which discusses the association between anorexia nervosa and depression. Psychopharmacological evidence and family genetics studies are reviewed. Suggestions for future research are also made.     

Psychological treatment of eating disorders

Significant progress has been achieved in the development and evaluation of evidence-based psychological treatments for eating disorders over the past 25 years. Cognitive behavioral therapy is currently the treatment of choice for bulimia nervosa and binge-eating disorder, and existing evidence supports the use of a specific form of family therapy for adolescents with anorexia nervosa. Important challenges remain. Even the most effective interventions for bulimia nervosa and binge-eating disorder fail to help a substantial number of patients. A priority must be the extension and adaptation of these treatments to a broader range of eating disorders (eating disorder not otherwise specified), to adolescents, who have been largely overlooked in clinical research, and to chronic, treatment-resistant cases of anorexia nervosa. The article highlights current conceptual and clinical innovations designed to improve on existing therapeutic efficacy. The problems of increasing the dissemination of evidence-based treatments that are unavailable in most clinical service settings are discussed.     

Demythologizing the attitudes of family caretakers about “mental illness”

This paper introduces the Boundary-Control Model. The model provides an account of the emergence, maintenance, and treatment of anorexia nervosa, with particular emphasis on the role of boundaries and control. The model delineates four basic emotional needs, which shape the adolescent's sense of self-worth. It assumes that when those needs are damaged, anxiety is induced and anorexia emerges as a defense mechanism. Treatment involves stripping away the adolescent's false sense of power by creating a crisis and provoking the hidden anxieties. The development and maintenance of anorexia nervosa, as well as its treatment, will be discussed in light of the proposed model.