Neurobiologically-Informed Treatment for Adults with Anorexia
Anorexia nervosa (AN) is a serious psychiatric disorder that is difficult to treat and is associated with significant medical and psychological complications. Approximately 50% of patients develop a persistent, relapsing, and remitting course. As such, identifying efficacious treatments for adults with AN is imperative. Accumulating behavioral and neuroimaging evidence supports a neurobiologically-based temperament that impacts the development and maintenance of AN—characterized by anxiety, reward insensitivity, perfectionism, altered interoceptive awareness, harm avoidance, and cognitive inflexibility, that is related to altered brain function (insula and fronto-striatal neural circuit). In addition to predating AN, mild to modest amounts of these traits often persist after recovery, suggesting those who recover might do so by effectively managing these traits. Yet, to date only a few therapies, such as Maudsley model of anorexia nervosa treatment for adults (MANTRA) are based on such an empirically supported understanding of AN, and none are administered in an intensive multifamily format with neurobiological psychoeducation and skills training.
To address this need, Wierenga and colleagues developed an intensive 5-day multifamily treatment for adult AN. The treatment includes psychoeducation to emphasize the key role of neurobiological factors in the development of AN, teaching the patient and Support (SU) age-appropriate skills to manage disorder-related temperament. In their study, Wierenga and colleagues examined the acceptability of the treatment for the patients and SUs, the feasibility of the treatment for the clinicians, and clinical outcomes (body mass index [BMI] changes, eating disorder symptoms, family functioning) after the study, and 3 months later. They reported that the 54 patients (each with at least 1 SU) rated the intervention as highly acceptable, and the clinicians noted good feasibility. At post-treatment, patients demonstrated significantly increased BMI, reduced eating disorder symptoms, and improved family function. Benefits were maintained in the 39 patients who completed follow-up assessment, with 62% reporting full or partial remission.
These preliminary results are promising, and suggest this novel treatment is feasible and acceptable. To establish treatment efficacy, fully-powered randomized controlled trials (to determine the effect of the intervention compared to other interventions, or no intervention) are necessary.
Anorexia nervosa (AN) is a severe, complex psychiatric condition that has both mental and physical manifestations. Like many other psychiatric conditions, AN can often present in variable ways, making treatment difficult and the recovery process slow. In light of particularly durable forms of the condition, there has been interest for research to focus on presentations of severe and enduring AN SEAN to determine predictors of and treatment options that better suit these cases. Approximately twenty per cent of cases fit into this subgroup, which often results in a life-long battle with the disease. Targeted approaches for the treatment of SEAN have been recommended, however, there is no consensus definition of SEAN to inform research and clinical practice.
Current definitions of SEAN emphasize illness duration, but thresholds vary, and illness duration likely is insufficient for characterizing SEAN. Among studies that have utilized illness duration to distinguish SEAN from earlier stage AN, cutoffs of 5, 6, 7, and 10 years have been reported. These thresholds have been based on clinical impressions and interpretations of existing literature, and evidence to support a categorical versus a dimensional approach to conceptualizing illness duration in AN is lacking. Furthermore, although additional criteria for SEAN have been proposed including repeated treatment failures, low body mass index (BMI), binge eating, purging (i.e., self-induced vomiting, laxative misuse, diuretic misuse), psychosocial impairment, and poor quality-of-life, few studies have incorporated these measures when defining groups, and the degree to which differences between SEAN and earlier stage AN reflect qualitatively distinct subgroups versus a continuum of severity or chronicity is unknown.
Wildes and colleagues have aimed to take initial steps toward developing an empirically based definition of SEAN. They suggest a model involving 3 Factors of Chronicity (dimensional) and 2 Profiles of Severity (categorical). Factor 1 Chronicity included eating disorder behaviors; Factor 2 comprised quality-of-life domains; and Factor 3 was characterized by illness duration, number of hospitalizations, and admission BMI. Profile 1 Severity was a group who experienced a lower level of symptoms, and Profile 2 Severity was a group who experienced a higher level of symptoms. They found that Severity Profiles differed on eating disorder behaviors (i.e., binging and purging) and impairment in health-related quality-of-life, but not on indicators of chronicity (i.e., illness duration, refractoriness to inpatient treatment, and low BMI). Chronicity Factor scores, but not Severity Profile membership, predicted outcome at discharge from treatment. Data suggest that individuals with AN can be classified on the basis of eating disorder behaviors and quality-of-life, but there was no evidence for a chronic subgroup of AN. Rather, indices of chronicity varied dimensionally within each class.
Given that current definitions of SEAN rely on illness duration, these findings have implications for research and clinical practice. At a conceptual level, it is important to acknowledge the limitations inherent in the construct of SEAN. In particular, severity and enduringness are dimensional concepts. Although it may be possible to “carve nature at its joints” in a way that has utility for clinicians and investigators in the field, individuals can present at any point along each of these continua. Thus, aspects of a SEAN definition (e.g., illness duration) may need to be conceptualized dimensionally. Furthermore, severity and enduringness are not necessarily correlated in AN. There are enduring, but mild forms of the illness (e.g., a person who maintains a low BMI for 20 years through dietary restriction and moderate exercise, but has no significant medical problems or psychosocial impairment). Likewise, there are severe, but shorter-term AN presentations (e.g., a teenager with symptom onset in the last year who presents with a very low BMI and serious medical complications secondary to purging). Thus, when we use the term SEAN, it must be with an awareness of these other groups and the complicated nature of the constructs we are studying. From a clinical perspective, Wildes and colleagues’ findings underscore the importance of a holistic approach to the assessment of severity and chronicity in eating disorders. Although factors like illness duration and repeated treatment failures play a role in explaining heterogeneity in AN, other variables that might be overlooked in routine practice also should be considered. In particular, their study highlights the importance of quality-of-life in distinguishing subgroups of AN.
- Wierenga CE, Hill L, Knatz Peck S, et al. The acceptability, feasibility, and possible benefits of a neurobiologically-informed 5-day multifamily treatment for adults with anorexia nervosa. Int J Eat Disord. 2018;00:1–7. https://doi.org/10.1002/eat.22876
About the Author: Heather, MSW, LICSW, QCSW, ACSW
Heather, MSW, LICSW, QCSW, ACSW has served on the Board of the National Eating Disorders Association (NEDA) since 2013 (including the Development Committee, Research Advisory Council, Conference Committee Co-Chair), and collaborates with her NEDA colleagues on Eating Disorder research studies, papers, and presentations. Through her position at Brown University Department of Psychiatry and Human Behavior, she has also been collaborating with her local Rhode Island Hospital/Hasbro Children’s Hospital Eating Disorders Partial Hospital, Outpatient, and Home-Based clinical programs since 2013. Heather had Anorexia Nervosa for 23 years, and has been recovered since 2012.