Short term structured treatments such as cognitive behaviour therapy and interpersonal psychotherapy, which are effective in other eating disorders, have not helped so far in patients with anorexia. One report found no difference in outcome between behaviour therapy and cognitive therapy.16
The preliminary results of a New Zealand study of cognitive behaviour therapy and interpersonal psychotherapy compared with usual treatment were disappointing.17
A cognitive behaviour therapy based “transdiagnostic” treatment for all eating disorders, including cases of anorexia where body mass index is above 15, has shown promise however.18
Expert consensus favours long term, wide ranging, complex treatments using psychodynamic understanding, systemic principles, and techniques borrowed from motivational enhancement therapy and dialectical behavioural therapy (box 2). These treatments should be delivered in various settings that cater for the level of intensity and degree of medical monitoring and care needed. The coordinated working of a wide range of medical and psychiatric services that do not usually work together will be needed. Because of the age group affected, and the time span involved, patients' care often undergoes many transitions. These are peak times for relapse and decompensation.
Box 2 Psychotherapies available for managing anorexia nervosa
- Structured individual treatments are usually offered as a weekly one hour session with a therapist trained in the management of eating disorders and in the therapy model used
Cognitive analytic therapy
- This psychotherapy uses letters and diagrams to examine habitual patterns of behaviour around other people and to experiment with more flexible responses
Cognitive behaviour therapy
- This psychotherapy explores feelings, educates patients about body chemistry, and challenges the automatic thoughts and assumptions behind behaviour in anorexia
- This psychotherapy maps out a person's network of relationships, selects a focus—such as role conflict, transition, or loss—and works to generate new ways to deal with distress
Motivational enhancement therapy
- This psychotherapy uses interviewing techniques derived from work with substance misuse to reframe “resistance” to change as “ambivalence” about change, and to nurture and amplify healthy impulses
Dynamically informed therapies
- These therapies may also result in weight gain and recovery provided the patient is aware of the risk of irreversible physical damage or death and acknowledges that certain boundaries (for example, that they must be weighed weekly, examined monthly by a doctor, and admitted to hospital if weight continues on a downward trend) are observed. The therapies involve talking, art, music, and movement
- There is little evidence that therapy for patients with anorexia benefits from being delivered in group sessions rather than individual sessions; in fact, group therapy may even worsen the problem. However, dialectical behaviour therapy offers structured groups in parallel with individual sessions. This therapy teaches skills that help patients to tolerate distress, soothe their feelings, and manage interpersonal relationships
- The term “family work” covers any intervention that harnesses the strengths of the family in tackling the patient's disorder or that tries to deal with the family's stress in the face of it. It includes family therapies, support groups, and psychoeducational input
- Evidence points to the effectiveness of the Maudsley model of family therapy and similar interventions focused on eating disorders. Whole families—or at least the parents and the patient—attend counselling sessions together, which can cause intolerable emotional stress
Separated family therapy
- The patient and the parents attend separate meetings, sometimes with two different therapists. This form of therapy seems to be as effective as conjoint therapy, particularly for older patients, and involves lower levels of expressed emotion
- Such groups provide a novel way of empowering parents by means of peer support and help from a therapist. Several families, including the patients, meet together for intensive sessions that often last the whole day and include eating together
Relatives' and carers' support groups
- These groups range from self help meetings to highly structured sessions led by a therapist that aim to teach psychosocial and practical skills to help patients with anorexia to recover while avoiding unnecessary conflict. Most encompass at least some educational input about the nature of anorexia
Early on, especially in younger patients, motivation for treatment lies with parents, schoolteachers, or medical professionals. The guiding principle of motivational enhancement is to acknowledge and explore rather than fight the patient's ambivalence about recovery. Treatment is more effective when the therapist and the patient work together against the anorexia. Such a relationship may allow the patient to be treated without having to invoke the Mental Health Act. Motivation is not an all or nothing battle to be won before treatment can start—it must be actively engendered throughout the treatment.
TIPS FOR NON-SPECIALISTS
- Recovery takes years rather than weeks or months, and patients must accept that they should attain a normal weight—refeeding alone may lead to relapse
- Trends should be monitored by weighing, which needs to be managed skilfully so it does not become a battleground
- No cut off weight or body mass index exists because many other factors influence risk
- Substance misuse—including alcohol, deliberate overdoses, or misuse of prescribed insulin—greatly increases risk
- Weight fluctuations and binge-purge methods (rather than pure restriction) increase risk
- Depression, anxiety, and family arguments are probably secondary to the disorder, not underlying causes, so the anorexia should be treated first
- Medication has little benefit in anorexia and the risk of dangerous side effects is high in malnourished patients
- Try to involve the family—encourage calm firmness and assertive care
Family work is the only well researched intervention that has a beneficial impact.19
Family work teaches the family and patient to be aware of the perpetuating features of the disorder. Fury, anger, and fighting lead to entrenched symptoms but too much permissiveness encourages the illness by allowing it to become an accepted response to stress, or—if the family will do anything to encourage the patient to eat—a route to providing “secondary gain” from the illness. Support of carers is essential to maintain the firm but sympathetic boundaries conducive to recovery
Early studies on teenagers with relatively recent onset anorexia showed that therapy involving the whole family was superior to treating just the patient. Further studies showed that, if tolerated, sessions involving the family and patient together gave the best results in terms of the family's psychological adjustment, but that weight gain was greater when families were seen separately from the patient.19
Both types of family intervention were more effective than individual work. More recently, “multi-family groups” have been piloted.20
The Maudsley group compared individual focused dynamic therapy, dynamically informed family therapy, individual cognitive analytic therapy, and “treatment as usual” over the course of a year.21
The dynamically informed therapies—both family and individual—produced the best results. The study showed that severely ill adults with anorexia could be managed as outpatients, and it highlighted the benefits of continuity of care by one therapist and of the expertise provided. However, nothing can be concluded about the specific model of therapy provided.
What is it like to experience anorexia nervosa?
At first I believed my thoughts were normal when I looked in the mirror—you don't expect your eyes to lie. I felt such self loathing that I drastically reduced my food intake and did a lot of exercise. I felt better about myself and decided that once I'd lost a pound or two I would eat normally again. When it came to it I was too scared. It felt good to lose a couple of pounds but it became addictive. If I did a certain amount of exercise one day, the next day I had to do at least the same amount. I ended up feeling physically rubbish, but my mind said I'm a horrible person who deserves pain.
Paranoia sets in. You're convinced people think you are fat even when they say you are not. Your mind tells you they are lying, until you find you can't trust anyone. Living with anorexia is a constant battle between two evils. On one hand eating feels like an evil thing, but other people see that very belief as the evil. When I feel I really must starve or exercise I get angry with the nurses. Other times it's a relief though, because at least they take the responsibility away from me.