Emerging directions in the treatment of AN center mostly on expanding our knowledge regarding the usefulness of atypical antipsychotics and developing more efficacious psychosocial treatments for adults with AN, including those aimed at relapse prevention (see ). Given the promising findings from trials involving olanzapine in increasing weight and improving cognitive symptoms of AN in adults, a 16-week, multi-site, double-blind, placebo-controlled outpatient trial of 160 adults with AN is currently underway to examine the effectiveness of olanzapine (2.5–10 mg) vs. placebo. This collaboration will increase knowledge about the outpatient efficacy of olanzapine, address limitations of small samples in previous studies (i.e., n = 15–34),17–20
and help identify the best dose.97
Given the paucity of efficacious psychosocial treatments for adults with AN, the National Institute of Mental Health established a request for applications that funded the development and evaluation of four novel treatments. These treatments were designed to target specific vulnerabilities for AN in older adolescents and adults.98–101
They include a couples-based treatment (UCAN),100,102,103
cognitive remediation therapy (CRT),98,104
emotion acceptance behavior therapy (EABT),99
and food exposure and response prevention therapy (AN-EXRP).101,105
While these trials are ongoing at the time of this review, preliminary results appear encouraging.
Uniting couples in the treatment of AN (UCAN) focuses on the patient in her interpersonal/social context, with the aim of maximizing social support and addressing issues of martial adjustment, communication, and sexual functioning.106
Given the strong support for family based therapy in children/young adolescents with AN, this treatment functions as a developmentally appropriate extension for adults with AN through a focus on couple, rather than family, functioning. Two integral aspects of family based therapies for adolescents have been the focus on engaging caregivers in the support and reinforcement of the refeeding process and improvement of overall family functioning. Within family based therapy, improved communication and family functioning serves to increase support within the environment and help the adolescent stay healthy, and improvement on the part of the patient contributes to improved family relationships. This sense of teamwork and focus on improved communication translates well to couples approaches, and is an important part of UCAN. Preliminary findings102,103
indicated impressive outcomes associated with both UCAN and the supportive couples’ therapy control condition. Although there was no significant difference between treatment conditions, retention, weight recovery, and remission exceeded levels observed in prior RCTs for outpatient treatment in adult patients with AN, suggesting partner involvement was beneficial.
CRT stems from neuropsychological research showing that individuals with AN exhibit weak central coherence, cognitive rigidity, and deficits in set shifting. These deficits are associated with an overly detail-oriented focus, which both maintains the disorder and interferes with traditional treatments, as patients often have difficulty grasping the therapeutic “big picture”.34
CRT targets these deficits through the use of cognitive exercises to improve thinking process skills and cognitive flexibility. This not only helps improve core cognitive symptoms of the disorder, but also enhances patients’ ability to engage in and benefit from therapies that directly target the eating disorder. Preliminary results104
support the acceptability of the treatment and improved performance on cognitive tasks for patients randomly assigned to receive CRT. The effects of improved cognitive processes on treatment engagement or outcome have not yet been reported.
EABT focuses on the role anorectic symptoms play in facilitating emotional avoidance. The treatment draws influence from several “third wave” treatments including acceptance and commitment therapy, DBT, and mindfulness-based cognitive therapy.107
EABT focuses on techniques to enhance emotional awareness and increase important relationships and activities for the patient outside of the eating disorder.107
In a recent case series, 3 of the 4 patients enrolled showed modest improvements in weight gain in an outpatient setting and additional improvements in anxiety, depression, and emotional avoidance were observed.107
AN-EXRP draws from similarities between AN and obsessive-compulsive disorder, including irrational fear/avoidance of food and extreme behaviors to manage these fears. Under this model, Steinglass and colleagues105
developed a treatment to confront patients’ anxiety around eating-related situations. These sessions begin with psychoeducation about the treatment and focus on developing an individualized hierarchy of feared foods, eating situations, and ritualized behaviors. Patients are then exposed slowly over time to each feared food situation, starting with the least feared item. Subjective ratings of anxiety are assessed immediately before, during, and after each exposure. The key aspect of exposure is the patient’s direct experience of, and habituation to, the anxiety as well as the disconfirmation of her feared consequences regarding eating. Steinglass and colleagues105
conducted a 4-week open series of AN-EXRP as an adjunct to inpatient treatment and found that decreases in anxiety over course of treatment were significantly associated with greater caloric intake in the post-treatment meal. However, change in weight was not reported, likely due to the inpatient setting of the study and success of normalizing weight in all participants.
In addition to trials conducted with the US, a German group108
has developed an internet-based relapse prevention program for AN. The program allows patients to receive daily information regarding healthy behaviors and pitfalls to avoid, report their symptoms, receive feedback about progress, and encouragement to contact their counselor for additional support if symptoms increase. Preliminary findings108
indicate that the interactive program was both successful in reducing relapse and contributed to further weight gain, suggesting its possible efficacy as an active treatment, compared to TAU.
Given the role that extreme exercise plays in maintaining the cognitive symptoms of AN, the Loughborough Eating Disorders Activity Therapy (LEAP)109
was developed as an adjunct to CBT to promote healthy attitudes toward exercise behavior. The program is structured around four core themes of psychoeducation about “healthy/non-excessive” exercise, guided discovery, cognitive skills, and relapse prevention. Preliminary data from 19 patients showed that 8 sessions of LEAP as an augment to inpatient treatment were successful in reducing anxiety, depression, extreme exercise and extreme beliefs about exercise. A double-blind international RCT is currently underway to examine the efficacy of LEAP enhanced CBT in the outpatient treatment of AN.110
In addition to treatments focused on adults, given the success of family based therapy for adolescents,37
two large trials are examining the cost-effectiveness of family based therapy modalities. Gowers and colleagues111
conducted a cost-effectiveness study in 167 patients and found that specialized outpatient family treatment was more cost-effective than general outpatient and inpatient treatment. Eisler and colleagues112
are currently conducting a large-scale, 12-month trial (n = 400) of multi-family day treatment compared to individual inpatient and outpatient family therapy. Multi-family day treatment is more intensive than outpatient treatment and is administered in group format. Group formats have advantages over single-family formats, including increased cost-effectiveness and increased opportunities for families to share their experiences with one another. Pragmatic studies such as these provide useful clinical information, given the often high cost of eating disorder treatment.111